Interventional Pain Management Specialists Help Get to the Bottom of Pain
Dr. Navid Farahmand, MD
Many people are unfamiliar with the condition called Piriformis Syndrome, especially when learning of its possible relationship to Sciatica pain. Sciatica, or the complaint of pain shooting down one’s leg, is a common problem that is often blamed on a pinched nerve within the spinal column. While this is an accurate assumption in many cases, I always advise my patients to remember that it’s not always the “big brother’s” fault. We can’t forget the little brother; Piriformis Syndrome (PS).
Sciatica can be caused by a pinching or irritation of the sciatic nerve outside the spinal column as well. To understand how this is possible, a brief description of the anatomy is helpful. The sciatic nerve is the large nerve carrying motor as well as sensory signals back and forth from the spine to the lower extremities, and is formed from the fusion of the L4, L5, and S1-S3 spinal nerves. These nerves exit the spine and ultimately fuse and exit the pelvis through an opening called the greater sciatic notch. As it exits though this opening, the sciatic nerve is essentially sandwiched between what I like to think of as two pieces of bread: the lower piece being the bony pelvis, and the upper piece being the piriformis muscle which ultimately is involved in the fluid movement of the hip. If the piriformis muscle is damaged, it can spasm or otherwise cause irritation of the sciatic nerve, now well outside of the spinal column.
With this anatomy lesson in mind, ladies and gentlemen, may I present to you the little brother, Piriformis Syndrome. PS is estimated to cause up to 6% of complaints of sciatica pain and discomfort. Approximately 50% of patients with PS have a history of direct trauma to the buttock, hip, or low back, and still other causes of Piriformis Syndrome include vigorous physical activity or hip replacement surgery. Patients often complain of low back, buttock, and/or hip pain that radiates down the leg.
Like siblings of different ages, treatment of Piriformis Syndrome has to be unique and different than the treatment of a pinched nerve occurring within the spinal column. More specifically, treatment is aimed at the offending piriformis muscle. Anti-inflammatory medication such as Ibuprofen (Motrin, Advil) and Acetominophen (Tylenol) can reduce inflammation and spasm. The application of heat, massage, and stretching can also decrease discomfort. In cases that don’t improve, a doctor specializing in performing injections (often times called interventional pain management) can safely and comfortably guide a needle into the piriformis muscle and inject it directly with local anesthetic and steroid medication to help numb the muscle and reduce inflammation, respectively. Infrequently, the piriformis muscle can continue to be irritated and spasm, causing continuous or recurrent complaints of sciatica. In such cases, the muscle can be injected with Botox or other similar medications that result in longer-lasting muscle paralysis, preventing further spasm and complaints of sciatica.
So, how do you know where to start in terms of treatment? Admittedly, sometimes it can be difficult to distinguish. As mentioned above, complaints of sciatica stemming from within the spine can sound very similar to complaints coming from Piriformis Syndrome, outside of the spinal column. That said, there are some clues that can help spine experts in making an accurate distinction and diagnosis. In cases where Piriformis Syndrome is to blame for the sciatica pain, complaints of numbness and tingling are less frequent, and as mentioned previously in about half the cases a history of trauma can be identified. Lastly, if an MRI of the spine fails to show significant cause for the problem within the spinal column, PS should be strongly considered. An open-minded interventional pain management physician will remember to keep Piriformis Syndrome as well as other possible causes for pain in mind and help you find the right treatment for your sciatica complaints.