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PIRIFORMIS SYNDROME the Piriformis Syndrome Is ISSUES & OPINIONS PIRIFORMIS SYNDROME The Piriformis Syndrome Is Overdiagnosed JOHN D. STEWART, MB, BS, FRCP(C) Department of Neurology and Neurosurgery, Montreal Neurological Hospital and McGill University, 3801 University Street, Room 365, Montreal, Quebec H3A 2B4, Canada Confusion reigns in the literature because the term lumbosacral nerve roots and of the paravertebral piriformis syndrome (PS) has been used to denote and pelvic areas must be normal to exclude radicu- four different entities. Which of these, if any, warrant lopathy, or lower lumbar or sacral plexus infiltration the designation PS? Each will be discussed in turn. or damage. Imaging of the pelvis and sciatic notch must show the absence of mass lesions there. The Damage to the Proximal Sciatic Nerve by Lesions in the significance of suspected abnormalities of the piri- Vicinity of the Piriformis Muscle. Lesions of the prox- formis muscle seen on imaging is uncertain, as dis- imal sciatic nerve in the area of the sciatic notch may cussed later. (4) Surgical exploration of the proxi- occur from endometriosis, tumors, hematomas, fi- mal sciatic nerve should confirm an absence of mass brosis, aneurysms, false aneurysms, or arteriovenous lesions. Ideally, compression of the sciatic nerve by malformations. Some authors have diagnosed such the piriformis muscle or associated fibrous bands patients as having PS. Since the piriformis muscle should be identified. However, it can sometimes be plays no role in these situations, such causes of sci- difficult to recognize a compressed nerve. (5) Relief atic neuropathy are best included under the rubric of symptoms and improvement in neurological ab- “proximal sciatic neuropathies.” normalities should follow surgical decompression. However, as in other situations of chronic nerve Compressive Damage to the Proximal Sciatic Nerve by damage, decompression may not always lead to the Piriformis Muscle. It has long been suggested symptom relief. Further, as discussed later, surgical that the proximal sciatic nerve can be compressed by division of the piriformis muscle has been described, the piriformis muscle where it crosses the nerve, and surprisingly, as relieving pain in patients with lum- that the frequent anatomical variations occurring bosacral radiculopathies. here predispose to this. Does such a condition exist? The older descriptions of alleged PS antedate This author proposes that, ideally, the following five modern imaging techniques, so these patients are criteria need to be fulfilled to define such a syn- excluded from further discussion. A few patients drome: (1) Presence of symptoms and signs of sciatic meet some of the criteria for PS, and a few others nerve damage. (2) Presence of electrophysiological very nearly meet the criteria. In one of the latter, the evidence of sciatic nerve damage. Paraspinal muscle surgical finding was a hypertrophied piriformis mus- electromyography (EMG) must be normal, to help cle compressing the sciatic nerve.7 Three patients in excluding a radiculopathy. (3) Imaging of the had bifid piriformis muscles compressing the lateral trunk of the sciatic nerve.2,4 Two patients had nerve compression by fibrous bands associated with the This article was prepared and reviewed by the AAEM and did not piriformis muscle.4,8 undergo the separate review process of Muscle & Nerve. Abbreviations: EMG, electromyography; MRI, magnetic resonance imag- Damage to the Sciatic Nerve by the Piriformis Muscle ing; PS, piriformis syndrome Key words: buttock pain; piriformis muscle; piriformis syndrome; sciatic and Adjacent Tissues from Trauma and Scarring. Ben- nerve; sciatica son and Shuster1 reported a series of patients with Correspondence to: American Association of Electrodiagnostic Medicine, 421 First Avenue SW, Suite 300 East Rochester, MN 55902, USA; e-mail: sciatic nerve lesions that they appropriately termed [email protected] “post-traumatic PS.” Symptoms began after blows to © 2003 American Association of Electrodiagnostic Medicine. Published by the buttocks. Several had electromyographic (EMG) Wiley Periodicals, Inc. studies showing abnormalities in muscles supplied by the sciatic and inferior gluteal nerves. One patient 644 Issues & Opinions: Piriformis Syndrome MUSCLE & NERVE November 2003 had myositis ossificans of the piriformis muscle, con- patients with conditions such as lumbosacral radicu- firmed at operation. Others had adhesions between lopathy, tumors or other masses at the sciatic notch, the piriformis muscle, the sciatic nerve, and the roof and posttraumatic scarring in this area. Tenderness of the sciatic notch. One patient had an anatomical therefore does not reliably indicate an abnormality anomaly of the sciatic nerve and piriformis muscle. of the piriformis muscle. All patients had a release of the piriformis tendon Further so-called evidence that the piriformis and their symptoms improved. muscle plays a role in these patients is the occur- rence of pain relief following local anesthetic or Chronic Buttock Pain with No Evidence of Sciatic Nerve corticosteroid injections into the piriformis muscle Damage. There are many reports of patients with and sciatic notch area. Unfortunately, this does not the primary symptom of buttock pain (often with elucidate the underlying pathology. Such injections “sciatica”) but no neurological deficits. In some, the will tend to relieve local symptoms regardless of the symptoms followed buttock trauma. These patients cause. Moreover, it is well established that nerve do not meet the criteria outlined above. They are blocks distal to a nerve lesion can produce pain labeled as having PS based on the belief that their relief.5 Deep buttock injections have been shown to symptoms are due to impingement on the proximal relieve pain in patients with lumbosacral radiculop- sciatic nerve by the piriformis muscle. athies and carcinomatous sacral root infiltration. The core issue here is the likelihood of chronic, One extraordinary study found that division of the or chronically recurrent compression of a peripheral piriformis muscle in patients with lumbosacral radic- nerve producing pain but no manifestations of nerve ulopathies produced pain relief.6 Thus, improve- fiber damage. In clear-cut compressive neuropa- ment of pain from injections and even from surgical thies, pain from nerve trunk involvement is almost division of the piriformis muscle cannot be used as always accompanied by sensory or motor symptoms, proof of sciatic nerve compression at that site. clinical deficits, and electrophysiological abnormali- The reports of a swollen piriformis muscle or ties. When this combination of features is absent abnormal signals in that muscle as seen on comput- (e.g., in the “disputed neurological” thoracic outlet erized tomography scanning or magnetic resonance syndrome and resistant tennis elbow syndrome), imaging (MRI) are difficult to interpret. Do such there is little convincing evidence that nerve trunks so-called abnormalities occur occasionally as inci- are involved in the genesis of symptoms. dental findings in otherwise normal persons? A frequent accompaniment of the buttock pain in this group of patients is sciatica. Most would ac- The Fishman Study. In 2002, Fishman and col- cept a definition for this term as being pain radiating leagues3 reported a series of 918 patients (1014 legs) down the leg from the lower back, buttock, or hip. with alleged PS. These investigators made a valiant Notwithstanding its name, such pain is not a specific attempt to create diagnostic criteria, to validate an indicator of sciatic nerve involvement. The most fre- electrophysiological test demonstrating sciatic nerve quent neurological cause is L-5 or S-1 radiculopathy; dysfunction, as well as to evaluate a nonsurgical treat- others include lower lumbar and sacral plexopathy ment protocol and results of surgery. Unfortunately, and proximal sciatic neuropathies. Non-neurologi- there are serious flaws in their methodology. The cal causes are more frequent and include musculo- entry criteria consisted of nonspecific symptoms and skeletal abnormalities of the lumbosacral spine and signs. Exclusionary criteria (imaging abnormalities hip, and pelvic disease. of the lower spine and pelvis) were not described. Much of the so-called evidence for this type of Standard electrophysiological studies of sciatic nerve “PS” rests on a variety of physical signs said to dem- function were not performed. The H-reflex testing onstrate pinching of the sciatic nerve by the pirifor- protocol used was based on normal values derived mis muscle during certain leg and hip maneuvers. from volunteers who may not have been age- These signs are all of doubtful validity in terms of matched to the patients. Treatments were broad- specifically demonstrating compression of the sciatic based and could benefit patients with a variety of nerve by the piriformis muscle. Several classic signs painful musculoskeletal disorders of the lower spine, in medicine have been shown to have poor sensitivity pelvis, and hips. Some treatment measures and their and specificity; for instance, Tinel’s and Phalen’s alleged effects were implausible; for instance, “myo- signs for carpal tunnel syndrome, and Adson’s ma- fascial release at the lumbosacral paraspinal mus- neuver for thoracic outlet syndrome. No sign said to cles” and “conservative treatment that lengthens the indicate PS has been critically evaluated. Tenderness piriformis muscle.” Most patients, regardless of the on deep palpation in the buttock is often found in number of clinical criteria
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