Piriformis muscle is located deep in the buttock and helps to rotate the leg outwards. It extends from the side of sacrum and tailbone to the upper part of thigh bone. One of the main nerves of the leg (sciatic nerve) runs in close relation to this muscle. Problems of the piriformis muscle such as spasms or swelling, can cause irritation of the sciatic nerve leading to sciatica like symptoms. This condition is addressed as piriformis syndrome (PS). Other names for this condition include extra-spinal sciatica, deep gluteal syndrome or wallet neuritis.

What are the symptoms of piriformis syndrome?

Most patients present with buttock and leg pain which is worse on sitting and with hip movements. Pain is described as a dull ache, shooting or burning sensation associated with buttock tenderness. Most patients sit with the affected side tilted upwards. Some patients complain of a swelling, sausage shaped lump sensation in the buttock. Pain commonly radiates towards hip or down the back of the thigh, leg. Walking upstairs or on inclines can increase pain, with relief on lying down. Sometimes when pain is severe it may cause individuals to limp while walking. In females there may be pain during sexual intercourse (dyspareunia).

What causes piriformis syndrome?

PS is six times more common in women and middle ages. Individuals sitting for prolonged periods (long-distance bikers, office workers) and occupations such as truck & taxi drivers, tennis players are at a higher risk. Variations in the anatomy of piriformis muscle, sciatic nerve or its path can predispose to the irritation of the nerve. In majority of individuals the nerve travels below the muscle, it may however travel through or over the muscle or may be split into two. Other causes of piriformis syndrome include

• Trauma or Injury to the muscle such as after a fall onto the buttock, surgery or lumbar and sacroiliac joint pathologies.
• Overuse and microtrauma such as during intense downhill or long-distance running/walking. This can cause muscle spasm and shortening.
• Direct compression as during sitting on hard surfaces may cause repetitive trauma
• Compression due to direct pressure from a tumour invasion, or abnormal dilatation of a nearby blood vessel (inferior gluteal artery aneurysm)
• Post-radiotherapy fatty atrophy of the piriformis muscle
• Altered leg, back or pelvis biomechanics

How is piriformis syndrome diagnosed?

The commonest cause of sciatica is the irritation of the nerves in or near the spine. PS represents an extra spinal cause where the site of nerve irritation lies outside the spine although the symptoms are similar. Correct diagnosis helps to offer targeted treatment and increases the probability of a successful outcome. Another nearby muscle (obturator internus) can cause similar symptoms and this needs to be differentiated from the PS.

Diagnosis begins with a comprehensive history and physical examination. An MRI is useful for detailed evaluation of the lumbar spine & pelvis and ruling out other conditions with similar presentation. X-rays can be used for the evaluation of neighbouring bony structures such as the hip and sacroiliac joints. Electromyography (EMG) may help in differentiating PS from pain originating from the spine.

A local injection into the piriformis muscle is often used to confirm the diagnosis. This is discussed in the treatments section.

What are the treatment options for piriformis syndrome?

Treatment involves a combination of the following;

• Short term rest and activity modification
• Lifestyle modification
• Physical therapy including stretching exercises of the piriformis, hamstring muscle and strengthening of the abductor and adductor muscles
• Medications including anti-inflammatories, muscle relaxants, neuropathic medications (ones used for nerve pain).

If these measures fail to resolve symptoms, then the next step is injections.

Ultrasound Guided Injections

Steroid injections are the most commonly used injection option. As stated previously injections can not only provide relief, but also help in confirming the diagnosis. Using ultrasound helps to improve accuracy and reduce chances of complications. X-rays guidance is an alternative, although ultrasound is preferred as it can be performed in outpatient settings and offers other advantages such as visualisation the piriformis muscle, blood vessels and the sciatic nerve. Local anaesthetic and steroid mixture is used for the injection. Local anaesthetics help to relax the muscle and steroids aid in reducing inflammation thus prolonging the effect of the injection.

Botox injections work by paralysing and relaxing the piriformis muscle, thereby taking the pressure off the sciatic nerve. The effect of these injections can last for a few months proving an opportunity to address the root cause and engage in physical therapy.

Surgery may be considered for severe cases not responding to other measures. It involves either cutting the piriformis tendon from its hip attachment or cutting through the piriformis muscle to take pressure off the sciatic nerve.

Return to sports and activities varies between individuals and depend on the time taken in reduction of the symptoms. Too early a return has the potential to cause worsening of injury and reoccurrence of the symptoms.

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Sciatica is term used to describe pain that travels (radiates) down the leg from the lower back or buttock. It is a type of nerve pain and a number of cases are caused by pressure on the nerves due to disc bulge in the low back. This is most commonly seen in middle-aged adults and men are more susceptible. The term sciatica originated from the sciatic nerve, which is the single largest nerve in our body. This nerve is responsible for a significant proportion of leg sensation and movement. Sciatica represents pain in the area supplied by the sciatic nerve.

Radicular pain/ radiculopathy are medical terms which doctors use when describing this condition. There are numerous reasons for having leg pain and every leg pain is not sciatica. Commonly people misinterpret sciatica as a disease and need to be explained that it is a symptom of the underlying problem.

2. What are symptoms of sciatica?

The severity and symptoms many vary considerably. In severe cases the affected individual may find it difficult to walk or even stand up straight.

Some of the commonly observed symptoms include

• Sharp, burning, stinging, shooting, electric shock or cramps like pain in one or both legs often as far down as the foot. Movement, coughing and sneezing can intensify the pain
• Tingling, pins and needles and/or numbness in leg or foot
• Muscle weakness with difficulty in weight bearing or walking.
• Buttock/low back pain and stiffness.

3. What causes sciatica?

• Disc herniation: Spine is formed of many bones called vertebrae arranged one above the other. In between these vertebrae are discs, which are like cushions or shock absorbers. The discs are made up of an outer tough substance and an inner soft jelly like substance. Herniation of the disc can occur if there is splitting or crack in the outer layers allowing the inner jelly like substance to protrude through the crack. This can cause inflammation and compression of the nerve roots in the vertebral column. Slipped disc is a commonly used term for this condition. There is an increased susceptibility to disc herniation as we age because the soft, jelly like substance dries out and shrinks with time, making the disc more fragile.
• Spinal stenosis: Stenosis means narrowing. The narrowing can be of the central canal of the spine or the passageways/ tunnels from which the nerves exit the spine. Besides disc problems, arthritis of the spinal joints or thickening of ligaments can also cause/ contribute to the narrowing.
• Spondylolisthesis: In this condition there is a problem with the alignment of vertebrae, where one vertebra is more forward or backwards, which can narrow the spaces for nerves and produce sciatica as a result.
• Piriformis syndrome: In this condition piriformis muscle in the pelvis is responsible for pressure on sciatic nerve.
• Trauma/ fractures
• Spinal tumors and infections are rare causes of sciatica

4. Can it resolve on its own?

Fortunately most cases of sciatica resolve within a period of weeks to months with conservative treatment. Specialist input and treatment can help. Painkillers, heat or cold pack, altered activity levels and physical therapy may be suggested depending on your condition. An injection of steroids into the epidural space within the spine can provide short-term pain relief in sciatica. Persistent pain can lead to changes in the nerves (referred to as plasticity). This can be a source of persistent pain even if the original inciting event is resolved … hence the importance of managing these sooner than later.

Having seen numerous cases over the years, I would say that it is not easy to predict the course. It can resolve but to what extend depends on numerous factors- some are modifiable and others are not. The recovery period varies from individual to individual.

5. What are the warning signs I need to be watch for?

Some symptoms point towards a serious problem and require urgent medical attention. Ignoring these could lead to permanent nerve damage. Some of these include

• Loss of urinary control/ inability to pass urine
• Loss of control over stools
• Numbness around the bottom
• Worsening leg weakness / loss of control

6. What can I do to reduce my risk of having sciatica?

Though it’s not possible to completely eliminate the risk of sciatica, however adopting a healthy life style can help in reducing the risk. This includes

• Giving up smoking
• Regular exercises
• Right posture and work ergonomics
• Healthy diet and maintaining weight in the normal range
• Using proper manual handling techniques while lifting to avoid back injury
• Stress Management

7. What investigations are generally considered for sciatica?

Your doctor may request for investigations such as magnetic resonance imaging (MRI) scan and blood tests. Sometimes computerized tomography (CT) scans may also be required. X-rays are not as helpful and they can provide only limited information.

Bulging discs on an MRI scan are not an uncommon finding. It is important not to get fixated on the MRI findings. A bulging disc is not permanent and can reverse. The investigation results should be interpreted in combination with patient history, examination findings to assess their significance. A number of patients with severe MRI findings may be asymptomatic and vice versa.

8. What are the other treatment options?

Sciatica is different from common ailments we all suffer and hence taking professional help is recommended. Your doctor can help to confirm that you have sciatica and help identify the cause. A range of different options- non surgical (such as injections- nerve root blocks, epidurals, piriformis injection etc) or surgical may be considered. There is no one solution for sciatica pain and the options are numerous – some with good evidence and others with not so robust evidence.

Generally a multimodal multidisciplinary approach is preferred as this helps in addressing not only the pain but also the impact of pain on one’s life. I ensure that the patient understands the nature or problem and the do’s and don’ts. Time spent in explaining the conditions and the expected course goes a long way in fostering realistic expectations. I generally use a combination of the modalities mentioned below to enhance the chances of quicker recovery.

Pain relief:
Pain reduction achieved by medicines help to maintain activity and improves physiotherapy compliance. The medications used depend on the type and severity of pain, duration of symptoms and individual factors such as co morbidities and allergies. Some of the commonly prescribed pain killers include

• Non steroidal anti-inflammatory drugs (NSAIDs)
  This includes drugs such as DIclofenac, Naproxen, Aceclofenac, Ibuprofen etc. NSAIDs are prescribed to reduce the pain and inflammation during periods of acute sciatica although the evidence supporting their use is not very robust. The risk benefit ratio needs to be evaluated while prescribing any drugs.
• Neuropathic pain killers
  This group includes antidepressants and anticonvulsants both of which are well known painkillers for nerve pain. It generally takes a few weeks for the full effects of these drugs to become apparent. Effects such as reduced anxiety and sedation can be used beneficially by tailored selection to suit individual patients. Their use is supported by the NICE guidelines, UK.
• Opioids
  Weak opioids such as tramadol are often prescribed during pain flare up episodes. It is a good practice to be aware of the side effects of a medicine prior to using it.
• Muscle relaxants
  These are used for short duration to relieve any muscle spasm contributing to the back pain.

Spinal Injections:

The use of epidural steroids/ Nerve root blocks has been shown to have beneficial improvements in leg pain and disability scores in short term. Steroids help by their anti-inflammatory and analgesic (pain relieving) effect. Epidural steroids are preferred to oral steroids as they are given close to site of actual problem and have less adverse effects.

Physiotherapy:

Physiotherapy is an essential component of sciatica treatment. Your physiotherapist can help with posture advice, do’s and don’ts relevant to your condition, understanding the concept of pacing of activities, setting practical goals, teaching strengthening exercises for core, leg muscles and manual handling techniques.

Surgery:

If a combination of above fails to provide adequate relief then surgical options such as discectomy (operation to remove bulging part of the disc or separated disc fragments) and microdiscectomy can be considered for sciatica resulting from disc bulge. Surgical options will vary depending on the cause of sciatica and sometimes may be the first choice, depending on the actual pathology and its severity.

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