Effective Stretching Positions of the Piriformis Muscle Evaluated Using Shear Wave Elastography.

CONTEXT: Piriformis syndrome is often associated with muscle spasms and shortening of the piriformis muscle (PM). Physical therapy, including static stretching of the PM, is one of the treatments for this syndrome. However, the effective stretching position of the PM is unclear in vivo. This study aimed to determine the effective stretching positions of the PM using ultrasonic shear wave elastography. DESIGN: Observational study. METHODS: Twenty-one healthy young men (22.7 [2.4] y) participated in this study. The shear elastic modulus of the PM was measured at 12 stretching positions using shear wave elastography. Three of the 12 positions were tested with maximum internal rotation at 0°, 20°, or 40° hip adduction in 90° hip flexion. Nine of the 12 positions were tested with maximum external rotation at positions combined with 3 hip-flexion angles (70°, 90°, and 110°) and 3 hip-adduction angles (0°, 20°, and 40°). RESULTS: The shear elastic modulus of the PM was significantly higher in the order of 40°, 20°, and 0° of adduction and higher in external rotation than in internal rotation. The shear elastic modulus of the PM was significantly greater in combined 110° hip flexion and 40° adduction with maximum external rotation than in all other positions. CONCLUSION: This study revealed that the position in which the PM was most stretched was maximum external rotation with 110° hip flexion and 40° hip adduction.

Evaluation of the Interrater Reliability of Sonographic Measurements of Muscle Thickness of 38 Piriformis Muscles in 19 Patients with Piriformis Syndrome.

BACKGROUND The piriformis muscle is a flat superficial muscle of the deep gluteal muscles that externally rotates the hip. Ultrasound is widely used to identify the piriformis muscle, especially for guidance of the needle during injections; however, its diagnostic use has recently gained popularity. The operator-dependent nature of ultrasound requires demonstration of reliability between operators. This study aimed to evaluate interrater reliability of sonographic measurements of muscle thickness of 38 piriformis muscles in 19 patients with piriformis syndrome. MATERIAL AND METHODS An ultrasound transducer was placed transversely on the sacral spinous process and moved caudo-laterally until the piriformis muscle was visualized under the gluteus maximus while patients were lying in prone position. The thickness of piriformis muscle was measured with a 2 to 5-MHz broadband curvilinear transducer in 3 regions (thickest regions of muscle over the ilium, near the greater trochanter, and near the sacrum). The interrater reliability of measurements of 2 examiners who were blinded to each other's measurements was assessed by intraclass correlation coefficient. RESULTS In total, 114 samples from 38 piriformis muscles of 19 patients with a diagnosis of piriformis syndrome were evaluated by 2 raters in this study. The median (interquartile range) patient age was 41 (15) years. Intraclass correlation coefficient value for overall thickness measurements of piriformis muscle was 0.836. Intraclass correlation coefficient values for 3 different regions were over the ilium, near the greater trochanter, and near the sacrum were 0.777, 0.883, and 0.811, respectively. CONCLUSIONS Ultrasound measurement of piriformis muscle thickness has good interrater reliability.

A Sciatic Neuralgia Case of an Entrapment Neuropathy Mimicking Piriformis Syndrome Due to Soft Tissue Hemangioma.

BACKGROUND: Lumbosacral pain is commonly seen in daily clinical practice. In fact, entrapment of the part of the sciatic nerve after the sacral foramen causes some of these pains, which should not be overlooked. The sciatic nerve may be compressed during its course after the sacral foramen for a variety of reasons. We aimed in this article to review extra-spinal compressive sciatic neuropathy reasons and abnormal magnetic resonance imaging (MRI) by presenting a sciatic neuralgia case of an entrapment neuropathy mimicking piriformis syndrome due to soft tissue hemangioma. CASE PRESENTATION: A 30-year-old male patient was admitted with complaints of lumbosacral pain spreading to the leg that had been worsening over the previous 10 days. With the preliminary diagnosis of labral damage and piriformis syndrome, the patient was referred to the radiology clinic for a hip MRI. In the hip MR images, a mass lesion suggestive of heterogeneously enhanced soft tissue hemangioma after the injection of paramagnetic contrast material was observed in the proximal left thigh. The soft tissue hemangioma extends towards the obturator foramen and compresses the sciatic nerve proximal to the femur after the sciatic foramen. CONCLUSION: The diagnosis of lower extremity entrapment neuropathy is frequently misdiagnosed. In these cases, MRI becomes more important for accurate diagnosis. The radiologists' knowledge of the sciatic nerve in MRI, regional anatomy during the course of the sciatic nerve, and abnormal nerve imaging findings will aid in the diagnosis.

Effects of ultrasound-guided platelet rich plasma injection in patients with piriformis syndrome.

BACKGROUND: Piriformis syndrome (PS) is the common entrapment neuropathy causing buttock pain. Patients are conventionally treated with lifestyle modification, exercise, non-steroidal anti-inflammatory drugs, corticosteroid or botulinum toxin injections. However, some patients may not respond to these conventional treatment methods. Platelet rich plasma (PRP) injection has been shown to be beneficial in various muscular injuries, but its effects have not yet been investigated in PS. OBJECTIVE: The aim of this study was to explore the effect of PRP on pain and functional status in patients with PS, and to identify any correlations between clinical changes and demographic features. METHODS: A total of 60 patients with PS were randomly separated into two groups (PRP and control groups). All patients received one session of either PRP or saline injection performed under ultrasound guidance. The pain was measured with a visual analog scale (VAS) and Oswestry Disability Index (ODI) scores were noted at three intervals in both groups: before treatment, 1 week after treatment and 1 month after treatment. RESULTS: The VAS and ODI scores were improved in both groups. The improvement was more obvious in the PRP group in the first week, and the results were similar for both groups when measured 1 month after the treatment. CONCLUSION: Ultrasound-guided PRP injection provided greater improvements in both pain and functional status in patients with PS, starting in the early period after treatment. A repeat injection might be needed for a long-term effect.

Piriformis syndrome: muscle thickness or volume does not correlate with response to CT-guided injection.

OBJECTIVE: To determine whether size of the piriformis muscle, as characterized by either the coronal width or a segmented volume, correlates with outcomes after CT-guided injections. MATERIALS AND METHODS: A consecutive series of 81 patients with piriformis syndrome received CT-guided injections of the sciatic nerve and piriformis muscle. Volume and thickness measurements of the piriformis were taken from T1W and T2W pre-injection images by two readers. A logistic regression was used to test volume and size effect on first injection response. A cox proportional hazards model was used to evaluate pain-free survival. Identical analyses were performed to test the effects of muscle mass abnormality, nerve abnormality, body mass index, and presence of a split sciatic nerve. RESULTS: There were 15/94 negative responses, 31/94 possible positive responses, and 48/94 positive responses to CT-guided injection. The average pain-free survival time was 38.91 ± 64.43 days. There was no significant correlation of first injection responses with muscle thickness or volume. There was no significant correlation in pain-free survival for muscle thickness or volume. There was no significant correlation in first injection response or pain-free survival with body mass index, muscle abnormalities, nerve abnormalities, or split sciatic nerves. The intraclass correlation was excellent between the two readers for both muscle volume (0.95-0.98) and thickness (0.92-0.97). CONCLUSION: Piriformis muscle volume or thickness did not significantly correlate with post-injection outcome (first injection response and pain-free survival). Thus, if the patient has clinical symptoms of piriformis syndrome, the size of muscle should not determine whether injection is advisable.

[Piriformis syndrome. Treatment under control of CT fluoroscopy]. / Sindrom grushevidnoi myshtsy. Lechenie pod kontrolem KT-skopii.

OBJECTIVE: To demonstrate one of the effective methods of treatment of the piriformis syndrome under the control of a highly technological visualization method. MATERIAL AND METHODS: Eight patients (7 women and 1 man), aged 44 to 63 years, with piriformis syndrome, were studied from 2016 to 2018. The main complaints of the patients were pain in the lumbosacral spine with irradiation to the gluteal region and/or legs. All patients underwent MRI and/or MSCT of the lumbosacral spine, the pelvic ultrasound, according to the results of which 1 patient was diagnosed with uterine myoma, 5 with lesions of intervertebral discs in the L4-L5 and L5-S1 segments of varying severity in combination with changes in posture. For therapeutic purposes, all patients under the control of CT fluoroscopy were administered to xeomin (n=3), dexamethasone (n=1) or betamethasone (n=4). RESULTS: In all patients, a positive therapeutic effect was observed after 4-12 months for xeomin injections, 2-3 weeks for dexamethasone and up to 3 months for betamethasone. No complications during the manipulations were observed. The authors present a clinical case to describe the botulinum therapy technique under the control of CT fluoroscopy, which allows effective treatment of the piriformis syndrome. CONCLUSION: In the treatment of the piriformis syndrome it is necessary to apply an integrated approach, the leading of which are methods of local impaction on the suffering muscle. Only a methodologically correct injection can increase the effectiveness of treatment in these patients and reduce the risk of complications.

Deep gluteal syndrome is defined as a non-discogenic sciatic nerve disorder with entrapment in the deep gluteal space: a systematic review.

PURPOSE: Clinicians are not confident in diagnosing deep gluteal syndrome (DGS) because of the ambiguity of the DGS disease definition and DGS diagnostic pathway. The purpose of this systematic review was to identify the DGS disease definition, and also to define a general DGS diagnostic pathway. METHODS: A systematic search was performed using four electronic databases: PubMed, MEDLINE, EMBASE, and Google Scholar. In eligibility criteria, studies in which cases were explicitly diagnosed with DGS were included, whereas review articles and commentary papers were excluded. Data are presented descriptively. RESULTS: The initial literature search yielded 359 articles, of which 14 studies met the eligibility criteria, pooling 853 patients with clinically diagnosed with DGS. In this review, it was discovered that the DGS disease definition was composed of three parts: (1) non-discogenic, (2) sciatic nerve disorder, and (3) nerve entrapment in the deep gluteal space. In the diagnosis of DGS, we found five diagnostic procedures: (1) history taking, (2) physical examination, (3) imaging tests, (4) response-to-injection, and (5) nerve-specific tests (electromyography). History taking (e.g. posterior hip pain, radicular pain, and difficulty sitting for 30 min), physical examination (e.g. tenderness in deep gluteal space, pertinent positive results with seated piriformis test, and positive Pace sign), and imaging tests (e.g. pelvic radiographs, spine and pelvic magnetic resonance imaging (MRI)) were generally performed in cases clinically diagnosed with DGS. CONCLUSION: Existing literature suggests the DGS disease definition as being a non-discogenic sciatic nerve disorder with entrapment in the deep gluteal space. Also, the general diagnostic pathway for DGS was composed of history taking (posterior hip pain, radicular pain, and difficulty sitting for 30 min), physical examination (tenderness in deep gluteal space, positive seated piriformis test, and positive Pace sign), and imaging tests (pelvic radiographs, pelvic MRI, and spine MRI). This review helps clinicians diagnose DGS with more confidence. LEVEL OF EVIDENCE: IV.

Anatomical analysis of the pelvis to identify any predisposing anatomical factors for ischiofemoral space pathology: a retrospective study.

OBJECTIVE: Anatomical analysis of the hips and pelvis was performed using MRI to evaluate morphological characteristics and associations between them. We identified correlations between the ischiofemoral space (IFS), quadratus femoris space (QFS), femoral version angle (FVA) and cervicodiaphyseal angle (CDA). METHODS: This study involved a retrospective search of a database of consecutive reports of adult hip MRI examinations carried out between January and September 2016. Patients with a medical history likely to affect pelvic and hip morphometry were excluded. RESULTS: A total of 137 adult patients were enrolled in the study (45.3% males and 54.7% females), with a mean age of 50.16 ± 13.87 years. The mean IFS was 20.88 ± 5.96 mm, mean QFS was 15.2 ± 6.18 mm, mean FVA was 12.43 ± 6.98, and mean CDA was 121.27 ± 4.6°. The IFS measurements were significantly correlated with femoral measurements (p = 0.025). These visible differences showed a slight negative relationship (-0.191), and females had a smaller distance between these anatomical structures than males (p < 0.001). Females had a significantly smaller QFS than males (12.42 ± 5.94 vs 18.73 ± 4.48 mm, p = 0.000). There was a small but significant positive relationship between CDA and FVA (p = 0.022), with a correlation coefficient of 0.195. CONCLUSION: A higher FVA was correlated with a smaller IFS. Furthermore, an increase in the CDA appeared in tandem with an increase in the FVA. ADVANCES IN KNOWLEDGE: A single conventional MRI sequence can alert us to how anatomical factors could predispose individuals to a decrease in IFS.

Piriformis Pyomyositis Presenting as Migratory Hip to Knee Pain: A Case Report.

CASE: The authors report a case of piriformis pyomyositis in a teenage female patient with fever and left hip pain. Her pain migrated to the knee with concurrent near resolution of hip pain. Imaging revealed an abscess in the left piriformis with pus tracking along the sciatic nerve sheath. This was complicated by internal iliac vein thrombosis and an embolus to the lung. Open drainage was performed, followed by outpatient intravenous cloxacillin and oral warfarin, with complete resolution of symptoms. CONCLUSION: Piriformis pyomyositis is a rare condition with varying presentations. The threshold for suspicion should be low even in healthy young individuals.

Computed Tomography-Guided Percutaneous Infiltrations for Piriformis Syndrome: A Single-Center Retrospective Study.

Piriformis syndrome (PS), first described by Yeoman in 1928, is a general term referring to low back pain, sciatica, and instability. PS has a 6% incidence rate worldwide. In this study, we aim to retrospectively evaluate the effectiveness of computed tomography (CT)-guided percutaneous infiltration in a series of consecutive PS patients who have symptoms that are refractory to conservative therapies. An institutional database search identified 20 such consecutive patients who underwent infiltration with a mixture of long-acting corticosteroid and local anesthetic. Preoperational evaluation included physical examination and magnetic resonance imaging. The correct position of the 22-gauge spinal needle was verified with CT scan after contrast medium injection. Pain measured before the procedure and at 1 wk and 1, 6, and 12 mo after the procedure was compared by means of a numeric visual scale (NVS) questionnaire. The mean pain score before CT-guided percutaneous infiltration was 8.95 ± 1.432 NVS units. This score was reduced to a mean value of 0.85 ± 0.933 units at 1 wk, 0.90 ± 0.852 at 1 mo, 1.10 ± 1.165 at 6 mo, and 1.20 ± 1.399 at 12 mo follow-up (p < 0.001). Two patients of 20 (10%) underwent a second infiltration that was performed at 7 and 10 d after the first, respectively. No complications were observed. CT-guided infiltration seems to be a feasible, efficacious, and safe approach for pain reduction and mobility improvement in patients with symptomatic PS.

Feasibility and Reliability of an Ultrasound Examination to Diagnose Piriformis Syndrome.

OBJECTIVE: We explored the diagnostic performance of ultrasound examinations in the diagnosis of piriformis syndrome (PS). METHODS: In our single-center retrospective study, 52 patients with a diagnosis of PS and 50 healthy volunteers were enrolled to undergo ultrasound examination of the piriformis and sciatic nerve. The thicknesses of the piriformis and the diameter of the sciatic nerve were measured to compare the differences between the patients with PS and healthy volunteers. The diagnostic performance of ultrasound examinations was assessed by constructing a receiver operating characteristic curve and calculating the area under the curve. RESULTS: In patients with PS, the piriformis and sciatic nerve were enlarged on the abnormal side compared with the asymptomatic side, accompanied by a decreased echo intensity and an unclear perineurium. In addition, the piriformis thickness and sciatic nerve diameter of those with PS were significantly greater than were those of the healthy volunteers. The diagnostic performance of ultrasonography was significant. The area under the receiver operating characteristic curve for piriformis thickness and sciatic nerve diameter to discriminate between the abnormal and asymptomatic sides was 0.778 and 0.871, respectively. CONCLUSION: Ultrasound examinations can assist in the clinical diagnosis of PS and have the potential to be an alternative method for the diagnosis of PS for most musculoskeletal clinicians.

Sciatic Nerve Variants in Patients Diagnosed With Sciatica: Is There a Correlation?

PURPOSE: Compression of the sciatic nerve in its path along the piriformis muscle can produce sciatica-like symptoms. There are 6 predominant types of sciatic nerve variations with type 1 being the most common (84.2%), followed by type 2 (13.9%). However, there is scarce literature on the prevalence of sciatic nerve variation in those diagnosed with sciatica. MATERIALS AND METHODS: The charts of 95 patients clinically diagnosed with sciatica who had a magnetic resonance imaging of the pelvis/hip were retrospectively studied. All patients had T1-weighted axial, coronal, and sagittal images. Magnetic resonance imagings were interpreted separately by 2 board-certified fellowship-trained musculoskeletal radiologists to identify the sciatic nerve variant. RESULTS: Seven cases were excluded because of inadequate imaging. Of the remaining 88 patients, 5 had bilateral sciatica resulting in a sample size of 93 limbs. Fifty-two (55.9%) had type 1 sciatic nerve anatomy, 39 (41.9%) had type 2, and 2 (2.2%) had type 3. The proportions of type 1 and 2 variations were significantly different from the normal distribution (P < 0.001), whereas type 3, 4, 5, and 6 variants were not (P = 1.00). CONCLUSIONS: There is strong statistical significance regarding the relationship between sciatic nerve variation and the clinical diagnosis of sciatica. Preoperative magnetic resonance imaging can be considered in sciatica patients to prevent iatrogenic injury in pelvic surgery.

Complementary Specific Pelvic Sequences on Routine Lumbar Magnetic Resonance Imaging Scans: An Imaging-Based Study Focused on Piriformis Syndrome.

AIM: To discuss the rationale and merit of specific pelvic sequences as an adjunct to routine lumbar magnetic resonance imaging (MRI) for early detection of piriformis syndrome (PS) and to disclose its frequency in patients who underwent radiological evaluation. MATERIAL AND METHODS: This retrospective, imaging-based study included all individuals who underwent lumbar MRI and those who were further evaluated with a pelvic MRI, but excluded all high-energy trauma cases. The patients' demographics and radiological features were reviewed using electronic patient records and hospital-based picture image archiving and communication system. RESULTS: Overall, 1321 individuals (659 females; 662 males) underwent lumbar MRI during the study period, and of these, 485 (238 females; 247 males) were further analyzed with a pelvic MRI for differential diagnosis. Forty patients (8.2%) (23 females; 17 males) were diagnosed with PS-all confirmed with MR neurography (MRN). On re-evaluation of all lumbar and pelvic MRIs and MRNs, we realized that adding just three specific pelvic sequences to routine lumbar MRI scans were enough to accurately delineate the piriformis muscle pathologies and sciatic nerve intensities. The calculated frequencies of PS in females, males, and the whole study population within 57 months were 3.49%, 2.57%, and 3.03%, respectively. CONCLUSION: Although PS being a clinical diagnosis, this study indicated that in patients whom PS was not suspected at the initial examination, 8.2% of them were finally diagnosed after MRI evaluations. Performing specific pelvic sequences as an adjunct to routine lumbar MRI can salvage underdiagnosed patients with PS and facilitate early detection of this pathological condition.

Quadratus Femoris muscle causing deep gluteal syndrome: A rare cause of refractory sciatica of extraspinal origin in the presence of an anatomic variation.

BACKGROUND: Sciatica of extraspinal origin represents both a diagnostic and a therapeutic challenge for spine specialists. Among these, quadratus femoris muscle (QF) is often overlooked as a pain-generator. REPORTED CASE: A 62-year old man was referred from general practitioner for isolated sciatica in the left leg, refractory to conservative treatments. Plain x-rays of the spine did not show any pathological finding nor did magnetic resonance imaging (MRI). MRI and CT showed QF with unusual morphologic features and agenesis of the contralateral QF. Ultrasonography-guided injection in the muscle was performed with mepivacaine and methylprednisolone obtaining relief of the symptoms. DISCUSSION: Leg pain can be very disabling and, when combined with a normal MRI of the spine, diagnosis can be tricky. Several causes of sciatica of extraspinal origin have been described, some of them originating from the so-called "deep gluteal space". Anecdotal communications on anatomical variations of the quadratus femoris muscle are reported in literature. CONCLUSIONS: Differential diagnosis of sciatica of extraspinal origin must rule out sacroiliac and hip joint so as deep gluteal space structures. Among these, quadratus femoris muscle is often overlooked as a pain-generator. Ultrasonography-guided intramuscular injections and a program of stretching and strengthening exercises can achieve durable control on the symptoms.

Ultrasound appears to be a reliable technique for the diagnosis of piriformis syndrome.

INTRODUCTION: Piriformis muscle syndrome (PS) is a disorder encompassing a constellation of symptoms, including buttock and hip pain. In this study we aimed to assess the value of ultrasound (US) in the diagnosis of PS. METHODS: Thirty-three clinically diagnosed PS patients and 26 healthy volunteers underwent a clinical PS scoring examination and US and MRI assessment of the bilateral piriformis muscles. The areas under the receiver operating characteristic curves (AUROCs) of the US parameters (i.e., increased thickness [iTh] and increased cross-sectional area [iCSA]) for piriformis muscle were evaluated. RESULTS: On US and MRI, the thickness and CSA were increased in PS patients. The AUROCs for the iTh and iCSA for discriminating stage 0 (healthy volunteers) from stage 1 through stage 3 (PS patients) were 0.88 and 0.95, respectively. DISCUSSION: US may be a reliable technique for the clinical diagnosis of PS. Muscle Nerve 59:411-416, 2019.

Targeted Ultrasound-Guided Perineural Hydrodissection of the Sciatic Nerve for the Treatment of Piriformis Syndrome.

Piriformis syndrome is a common cause of lumbar, gluteal, and thigh pain, frequently associated with sciatic nerve symptoms. Potential etiologies include muscle injury or chronic muscle stretching associated with gait disturbances. There is a common pathological end pathway involving hypertrophy, spasm, contracture, inflammation, and scarring of the piriformis muscle, leading to impingement of the sciatic nerve. Ultrasound-guided piriformis injections are frequently used in the treatment of these pain syndromes, with most of the published literature describing injection of the muscle. We describe a safe, effective ultrasound-guided injection technique for the treatment of piriformis syndrome using targeted sciatic perineural hydrodissection followed by therapeutic corticosteroid injection.

Effect of Mannitol plus Vitamins B in the management of patients with piriformis syndrome.

BACKGROUND: Piriformis syndrome (PS) is an entrapment of the sciatic nerve by the piriformis muscle, or myofascial pain from the piriformis muscle. OBJECTIVE: The aim of this study was to investigate the effectiveness of Mannitol plus Vitamins B regime in the management of PS. METHODS: Twenty two patients were included in this study and received 250 ml of mannitol 20% intravenous infusion for 5 days + Vitamins B (vitamin B1 10 mg + vitamin B2 10 mg + vitamin B12 50 µg PO) for 6 weeks. Clinical outcomes were assessed systematically by clinical tests (tenderness, FAIR test, Beatty's, Freiberg's and Pace's maneuver), Numeric Rating Scale (NRS), Likert Analogue Scale (LAS), and MR examination. RESULTS: The clinical evaluations showed a significant reduction (p< 0.05) of tenderness, FAIR test, Beatty's maneuver, Freiberg's maneuver and Pace's maneuver when compared with baseline evaluation during the 3rd and 6th month follow-ups. A statistically significant improvement of pain was measured by NRS at resting (p< 0.001), at night (p< 0.001) and during activities (p< 0.001) and LAS with prolonged sitting (p< 0.001), standing (p< 0.001) and lying (p< 0.001). Concomitantly, swelling of SN revealed a significant reduction (p= 0.003) from 86.4% to 18.2%. CONCLUSIONS: Mannitol plus Vitamins B is effective in the management of piriformis syndrome and it could be an alternative regime in treating PS.

Epidemiology and etiology of secondary piriformis syndrome: A single-institution retrospective study.

Piriformis syndrome (PS) is a rare etiology of extra-spinal sciatica in which pathologies associated with or around the piriformis muscle (PM) irritate the adjacent sciatic nerve (SN), however, there is scarcity in the literature regarding its exact etiologies, thus, we performed a retrospective study to elucidate the epidemiology of PS and assess various causes of the syndrome. Our study included patients assessed at our institution who presented with sciatica of non-spinal origin between May 2014 and December 2015. Radiology reports of all patients who received pelvic MRI were examined for positive findings involving PM and SN. Of the 143 patients recognized with sciatica and negative lumbar pathology, 24 patients (17%) exhibited positive PM and SN findings. Average patient age was 50.0 ±â€¯15.1 years (range: 21-75), and 17 were female. Seven patients (5%; 4M/3F) presented with tumor, seven patients (5%) had chronic inflammatory changes, one patient had SN adhesions to obturator muscle, three patients (2%, 3F) had aberrant anatomy, and the remaining patients had positive MRI findings, such as nerve atrophy or PM hypertrophy without identifiable cause. Seven patients received steroid injections in the peri-sciatic fossa, and four displayed poor response. Our findings suggested possible trends in extra-spinal sciatica. Affected males appeared more likely to present with tumor, while affected females were more likely to present younger, but with aberrant anatomy. Steroid injections appeared to be suboptimal in most cases. Pelvic MRI is helpful in patients with sciatica and negative spine imaging to rule out neoplastic involvement.

Endoscopic treatment of sciatic nerve entrapment in deep gluteal syndrome: Clinical results. / Manejo endoscópico del atrapamiento del nervio ciático en el síndrome de glúteo profundo: resultados clínicos.

INTRODUCTION: Deep gluteal syndrome (DGS) is characterized by compression, at extra-pelvic level, of the sciatic nerve within any structure of the deep gluteal space. The objective was to evaluate the clinical results in patients with DGS treated with endoscopic technique. METHODS: Retrospective study of patients with DGS treated with an endoscopic technique between 2012 and 2016 with a minimum follow-up of 12 months. The patients were evaluated before the procedure and during the first year of follow-up with the WOMAC and VAIL scale. RESULTS: Forty-four operations on 41 patients (36 women and 5 men) were included with an average age of 48.4±14.5. The most common cause of nerve compression was fibrovascular bands. There were two cases of anatomic variant at the exit of the nerve; compression of the sciatic nerve was associated with the use of biopolymers in the gluteal region in an isolated case. The results showed an improvement of functionality and pain measured with the WOMAC scale with a mean of 63 to 26 points after the procedure (P<.05). However, at the end of the follow-up one patient continued to manifest residual pain of the posterior cutaneous femoral nerve. Four cases required revision at 6 months following the procedure due to compression of the scarred tissue surrounding the sciatic nerve. CONCLUSION: Endoscopic release of the sciatic nerve offers an alternative in the management of DGS by improving functionality and reducing pain levels in appropriately selected patients.

[Tendonitis calcarea of the piriformis muscle in a young amateur athlete]. / Tendinitis calcarea des M. piriformis bei einer jungen Amateursportlerin.

Distinct calcific tendonitis associated with chronic pain refractory to conservative treatment can require operative treatment. Symptomatic calcific tendonitis of the piriform muscle, despite calcific tendonitis of other regions, is an extremely rare diagnosis. We report about a young athlete with persistent gluteal pain despite long-term conservative treatment. MRI scans revealed tendonitis calcarea with surrounding soft tissue inflammation. On open surgical removal of the calcification, pain symptoms were relieved and the patient was able to return to sports.