Piriformis Steroid Injection – Indication, Contraindication

Indications of Piriformis Steroid Injection

Piriformis syndrome may be responsible for 0.3% to 6% of all cases of low back pain? and/or sciatica?. With an estimated amount of new cases of low back pain? and sciatica at 40 million annually, the incidence of piriformis syndrome would be roughly 2.4 million per year. In the majority of cases, piriformis syndrome occurs in middle-aged patients with a reported ratio of male to female patients being affected 1:6.

Contraindications of Piriformis Steroid Injection

Two components contribute to the clinical? presentation of piriformis syndrome: somatic and neuropathic. The somatic component is a myofascial pain component of the syndrome secondary to any of the surrounding muscles/fascia? (i.e. any of the short external rotators of the hip). The neuropathic component refers to the compression or irritation of the sciatic nerve? as it courses through above, near, or through, the piriformis muscle itself.

Patients may present acutely in cases of post-traumatic piriformis syndrome or insidiously as in cases of overuse or myofascial pain. Patients will report having gluteal pain with possible associated paresthesias in the back, groin?, perineum, buttocks, hip, back of the thigh, calf, foot, and rectum?. There is also intense and worsened pain with sitting or squatting.

Preparation of Piriformis Steroid Injection

Initial evaluation should start with a lumbar spine? examination. The examination should take into account the patient’s gait, posture, and alignment as well as any leg length discrepancies. Also, the practitioner should examine the patient’s hips, pelvis?, and the sacroiliac joint, noting sensory, motor, and deep tendon? reflexes.

In piriformis syndrome, sensory, motor, and deep tendon reflexes are normal. The piriformis should be palpated as well just posterior to the hip joint? and in the area of the greater sciatic notch.   Straight leg raise may also be positive although there is variable sensitivity and specificity for this provocative maneuver.

There are individual tests that stretch the piriformis and can be used to help aid in the diagnosis of exclusion. One of these is the Freiberg sign, which is performed by putting the hip in extension and internal rotation and having the patient externally rotate against resistance. The positive exam will reproduce pain around the piriformis. This test will have positive results in up to 63% of patients. Another individual test called the Pace sign is performed by resisting abduction and external rotation of the hip while the patient is in a seated position. Pace sign occurs in 30% to 74% in piriformis syndrome. FAIR test or also known as the piriformis stretch may elicit pain. Beatty sign has also been described and is accomplished by elevating the flexed leg on the irritated side while the patient lies on the asymptomatic? side. Pain and reproduction of the symptoms are a positive test result.

Technique

No definitive diagnostic criteria has been validated and established for piriformis syndrome.  It remains a diagnosis of exclusion, but many of the following exam findings can aid the clinician in honing in on this diagnosis:

• Unilateral? or bilateral buttock pain with fluctuating periods of pain throughout the day
• No lower back pain,
• No pain upon palpation of axial spine
• Negative results for straight leg raise
• Prolonged sitting triggering gluteal pain or sciatica
• Fluctuating sciatica through the course of the day
• Buttock pain near projection of the piriformis reproduced by FAIR or Freiberg sign or Beatty sign, or palpitations
• The absence of perineal irradiation
• Sciatica reproduced by FAIR, Freiberg sign, or Beatty sign.

Standard radiographs of the pelvis and hip should be done to rule out underlying hip pathology. MRI of the lumbar spine is also recommended to evaluate for a discogenic causes of lumbar radiculopathy and to rule out other sources of compression (e.g. soft tissue tumors or masses).  MRI can also evaluate for spinal stenosis, herniated disks, facet arthrosis, SI joint pathology, occult pelvic fractures, and any surrounding tendinopathies or bursitides.

EMG is often normal in patients with acute piriformis syndrome presentations, however, chronically, EMG/NCS can be useful in identifying neuropathic changes and abnormal results in muscles innervated by the sciatic nerve [rx].

Solution (injectable):

• Corticosteroids: 40-mg of Depo-Medrol or Kenalog
• Local anesthetics: 3-5-ml of local anesthetic such as lidocaine or bupivacaine
• It is also done with botulinum toxin for longer relief than steroid and local anesthetic.

Patient Position: Prone

Fluoroscopy starting position:

• An A-P view is adjusted so that the inferior part of the sacroiliac joint is in the middle of the screen.

Piriformis Muscle Injection with Fluoroscopic Guidance

• 18-gauge 1.5″ needle tip is placed on the cleaned skin over the inferior SI joint.
• Create a skin wheal and then anesthetize the deeper subcutaneous skin with 1% lidocaine and a 27-gauge 1.25-inch needle.
• A 22-gauge 3.5″ or 5″ Quincke needle is used to contact the very tip of the inferior sacroiliac joint. As the procedure is performed, note of the approximate needle depth.
• After injection, the needle is withdrawn and redirected to a target site 1-cm inferior, 1-cm lateral, and 1-cm deeper than the SI joint.

Caution: Never inject if the patient feels a sharp pain shooting down their leg as the needle tip may be inside the sciatic nerve. The needle should be repositioned and then retry.

Complications

Nonoperative

Treatment for piriformis syndrome begins with nonoperative modalities including:

• Oral analgesics (e.g. NSAIDs, muscle relaxants, and gabapentin)
• Physical therapy:

  • Regimens include nerve stretches, isometric exercises, gluteal muscle strengthening
• Injections

  • Diagnostic and therapeutic modalities
  • Agents used include cortisone, local anesthetic, or botulinum toxin
  • A recent study reported positive outcomes in patients managed with physical therapy and Botulinum toxin injection

Surgical treatment

• Surgery is considered in refractory cases after exhausting nonoperative modalities
• A 2005 study reported surgical outcomes in 64 patients managed with surgical intervention for refractory symptoms: [rx]

  • 82% reported initial improvement
  • 76% had long-term positive outcomes
  • 92% of those managed with surgery returned to work or presurgical baseline activity levels within 2 weeks of the surgery

References