Left Gluteal Maximus Neuroma Causing Long-Standing Gluteal Pain.

ABSTRACT: Diagnosing buttock pain is a challenge due to complex anatomy and multiple causes. Potential pathologies range from common and benign to rare and life-threatening. Common causes for buttock pain include referred pain from the lumbar spine and sacroiliac joint, hamstring origin tendinopathy, myofascial pain, ischiogluteal bursitis, gluteal pathology, and piriformis syndrome. Rarer causes include malignancy, bone infection, vascular anomalies, and spondyloarthropathies. Other conditions may be present concurrently in the lumbar and gluteal area, which can cloud the clinical picture. Correct diagnosis and early treatment may improve quality of life by providing a targetable reason for their distress, improving pain, and allowing the patient to get back to their activities of daily living. When treating a patient with buttock pain, it is essential to reevaluate the diagnosis when symptoms fail to improve despite appropriate intervention.Here, we discuss a case of a peripheral nerve sheath tumor found in the left gluteus medius muscle of a patient that caused persistent, debilitating buttock pain. After years of treatment for piriformis syndrome and possible spinous causes, the patient was ultimately diagnosed with a peripheral nerve sheath tumor through magnetic resonance imaging with contrast. Peripheral nerve sheath tumors are a diverse group of mostly benign tumors that can occur sporadically or associated with certain disease processes. These tumors usually present with pain, a soft tissue mass, or focal neurological deficits. Upon removal of the tumor, her gluteal pain completely resolved.

Is it painful to be different? Sciatic nerve anatomical variants on MRI and their relationship to piriformis syndrome.

OBJECTIVES: To investigate the purported relationship between sciatic nerve variant anatomy and piriformis syndrome. METHODS: Over 49 months, 1039 consecutive noncontrast adult hip MRIs were completed for various clinical indications. Repeat and technically insufficient studies were excluded. Radiologists categorized sciatic nerve anatomy into Beaton and Anson anatomical types. Chart review using our institution's cohort search and navigation tool determined the prevalence of the explicit clinical diagnosis of piriformis syndrome (primary endpoint) and sciatica and buttock pain (secondary endpoints). A Z-test compared the prevalence of each diagnosis in the variant anatomy and normal groups. RESULTS: Seven hundred eighty-three studies were included, with sciatic nerve variants present in 150 hips (19.2%). None of the diagnoses had a statistically significant difference in prevalence between the variant and normal hip groups. Specifically, piriformis syndrome was present in 11.3% of variant hips compared with 9.0% of normal hips (p = 0.39). CONCLUSIONS: There were no significant differences in the prevalence of piriformis syndrome, buttock pain, or sciatica between normal and variant sciatic nerve anatomy. This large-scale correlative radiologic study into the relationship between sciatic nerve variants and piriformis syndrome calls into question this purported relationship. KEY POINTS: • Large retrospective study relating variant sciatic nerve anatomy, present in 19.2% of hip MRIs, and piriformis syndrome • While sciatic nerve variant anatomy has previously been implicated in piriformis syndrome in small studies, no relationship was identified between sciatic nerve variants and piriformis syndrome.

Four symptoms define the piriformis syndrome: an updated systematic review of its clinical features.

PURPOSE: To update the evidence on the clinical features of the piriformis syndrome since the first systematic review published in 2010. METHOD: A systematic review of all case, cross-sectional and prevalence studies. RESULTS: The commonest features reported were: buttock pain, pain aggravated on sitting, external tenderness near the greater sciatic notch and pain on any maneuver that increases piriformis muscle tension, and limitation of straight leg raising. The quality of case reports since the previous review has not improved with considerable under-reporting of presumed negative tests. Three recent cross-sectional and prevalence studies have been reported, but the two larger studies are at high risk of bias. CONCLUSIONS: Piriformis syndrome can be defined by a quartet of symptoms and signs. Many physical tests have been described, but the accuracy of these tests and the symptoms cannot be concluded from studies to date. Straight leg raising does not rule out the diagnosis. Piriformis syndrome is at a stage previously encountered with herniated intervertebral disc: that piriformis muscle pathology can cause sciatica has been demonstrated, but its prevalence among low back pain and sciatica sufferers and the diagnostic accuracy of clinical features requires cross-sectional studies free of incorporation and verification biases. One small cross-sectional study provides an encouraging example of how such studies could be conducted but would need replication in a broader population and better reporting.

Refractory sciatica caused by gluteal varicosities.

We report a case of sciatica that fulfilled the diagnostic criteria for inferior gluteal vein varicosities according to patient history and on magnetic resonance imaging. Since conservative treatment was ineffective, excision-ligation of the varicose vein was performed as recommended in the previous literature. However, pain was only slightly relieved and then aggravated. Reoperation involving wide release and resection of the piriformis outlet was performed. Pain resolved immediately thereafter. We suggest that this case of sciatica resulted from both piriformis entrapment and vein varicosities. The piriformis entrapment led to inferior gluteal vein backflow obstruction, and varicosities could have been the trigger of piriformis syndrome. Excision-ligation of the varicose vein and piriformis release were recommended.

Piriformis syndrome: a cause of nondiscogenic sciatica.

Piriformis syndrome is a nondiscogenic cause of sciatica from compression of the sciatic nerve through or around the piriformis muscle. Patients typically have sciatica, buttocks pain, and worse pain with sitting. They usually have normal neurological examination results and negative straight leg raising test results. Flexion, adduction, and internal rotation of the hip, Freiberg sign, Pace sign, and direct palpation of the piriformis cause pain and may reproduce symptoms. Imaging and neurodiagnostic studies are typically normal and are used to rule out other etiologies for sciatica. Conservative treatment, including medication and physiotherapy, is usually helpful for the majority of patients. For recalcitrant cases, corticosteroid and botulinum toxin injections may be attempted. Ultrasound and other imaging modalities likely improve accuracy of injections. Piriformis tenotomy and decompression of the sciatic nerve can be done for those who do not respond.

Piriformis syndrome--a rare cause of extraspinal sciatica.

Piriformis syndrome is a rare entity resulting in severe unilateral isolated buttock pain shooting in nature, non discogenic in origin. MR imaging of pelvis plays an important role in such patients to see the normal anatomy of piriformis muscle and its relationship with sciatic nerve. A 35-year-old woman presented with one year history of radiating leg pain with normal MR lumbosacral spine. MRI pelvis showed an abnormal orientation of left sciatic nerve through cleaved fibers of the piriformis muscle. The patient's symptoms were relieved by surgical decompression. The purpose of this case report is to show the role and importance of MR imaging for tracing sciatic nerve and its relationship to the Piriformis muscle. MR imaging of pelvis for sciatic nerve plays an important role in symptomatic patients with isolated buttock pain having normal MRI lumbosacral spine.

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.

Amyloid Deposition: An Unusual Case of Deep Gluteal Syndrome and Sciatic Nerve Compression: A Case Report.

CASE: Soft-tissue amyloidomas are exceedingly rare, with only a few cases reported in the literature. There are no reports of sciatic nerve compression secondary to a soft-tissue amyloidoma. We report a unique case of a 71-year-old man with an incidentally found amyloidoma who was initially believed to have deep gluteal syndrome. He had a favorable outcome after surgical decompression. CONCLUSION: For patients who do not have classic examination and electromyography/nerve conduction findings of piriformis syndrome, providers should explore other etiologies of peripheral nerve compression including soft-tissue amyloidoma.

Botulinum toxin injections for low-back pain and sciatica.

BACKGROUND: Adequate relief from low-back pain (LBP) is not always possible. Emerging evidence suggests a role for botulinum neurotoxin (BoNT) injections in treating pain disorders. Proponents of BoNT suggest its properties can decrease muscle spasms, ischemia and inflammatory markers, thereby reducing pain. OBJECTIVES: To determine the effects of botulinum toxin injections in adults with LBP. SEARCH STRATEGY: We searched CENTRAL (The Cochrane Library 2009, issue 3) and MEDLINE, EMBASE, and CINAHL to August 2009; screened references from included studies; consulted with content experts and Allergan. We included published and unpublished randomised controlled trials without language restrictions SELECTION CRITERIA: We included randomised trials that evaluated BoNT serotypes versus other treatments in patients with non-specific LBP of any duration. DATA COLLECTION AND ANALYSIS: Two review authors selected the studies, assessed the risk of bias using the Cochrane Back Review Group criteria, and extracted the data using standardized forms. We performed a qualitative analysis due to lack of data. MAIN RESULTS: We excluded evidence from nineteen studies due to non-randomisation, incomplete or unpublished data. We included three randomised trials (N =123 patients). Only one study included patients with chronic non-specific LBP; the other two examined unique subpopulations. Only one of the three trials had a low risk of bias and demonstrated that BoNT injections reduced pain at three and eight weeks and improved function at eight weeks better than saline injections. The second trial showed that BoNT injections were better than injections of corticosteroid plus lidocaine or placebo in patients with sciatica attributed to piriformis syndrome. The third trial concluded that BoNT injections were better than traditional acupuncture in patients with third lumbar transverse process syndrome. Both studies with high risk of bias had several key limitations. Heterogeneity of the studies prevented meta-analysis. There is low quality evidence that BoNT injections improved pain, function, or both better than saline injections and very low quality evidence that they were better than acupuncture or steroid injections. AUTHORS' CONCLUSIONS: We identified three studies that investigated the merits of BoNT for LBP, but only one had a low risk of bias and evaluated patients with non-specific LBP (N = 31). Further research is very likely to have an important impact on the estimate of effect and our confidence in it. Future trials should standardize patient populations, treatment protocols and comparison groups, enlist more participants and include long-term outcomes, cost-benefit analysis and clinical relevance of findings.

The clinical features of the piriformis syndrome: a systematic review.

Piriformis syndrome, sciatica caused by compression of the sciatic nerve by the piriformis muscle, has been described for over 70 years; yet, it remains controversial. The literature consists mainly of case series and narrative reviews. The objectives of the study were: first, to make the best use of existing evidence to estimate the frequencies of clinical features in patients reported to have PS; second, to identify future research questions. A systematic review was conducted of any study type that reported extractable data relevant to diagnosis. The search included all studies up to 1 March 2008 in four databases: AMED, CINAHL, Embase and Medline. Screening, data extraction and analysis were all performed independently by two reviewers. A total of 55 studies were included: 51 individual and 3 aggregated data studies, and 1 combined study. The most common features found were: buttock pain, external tenderness over the greater sciatic notch, aggravation of the pain through sitting and augmentation of the pain with manoeuvres that increase piriformis muscle tension. Future research could start with comparing the frequencies of these features in sciatica patients with and without disc herniation or spinal stenosis.

Posterior femoral cutaneous neuropathy in piriformis syndrome: A vascular hypothesis.

Piriformis syndrome is described as a neuromuscular condition which occurs when the sciatic nerve is compressed and/or irritated by the piriformis muscle. It is characterized by acute tenderness in the buttock with sciatica-like pain radiating into the posterior aspect of the thigh, leg, and foot. The neurogenic leg and foot pain experienced with this condition is consistent with involvement of the sciatic nerve. However, the posterior thigh pain associated with piriformis syndrome is due to involvement of the posterior femoral cutaneous nerve (i.e., posterior cutaneous nerve of the thigh), which is a branch of the sacral plexus independent of the sciatic nerve. This nerve is rarely mentioned relative to piriformis syndrome even though posterior thigh pain is more prevalent in patients than leg and foot pain. In the few instances when the posterior femoral cutaneous nerve is referenced relative to piriformis syndrome the neuralgic signs associated with it are attributed to compression by piriformis. Yet, given the dramatic size difference between the sciatic and posterior femoral cutaneous nerves one would expect direct piriformis compression to impact the sciatic nerve first and produce leg/foot pain at a far greater frequency than posterior thigh pain. However, the opposite is seen in the literature, which raises the question, what underlying mechanism is responsible for this phenomenon? It is hypothesized that the prevalence of posterior femoral cutaneous nerve involvement in piriformis syndrome is due to compression of the inferior gluteal vein by a hypertrophied piriformis muscle.

[Assessing the treatment for sacroiliac joint dysfunction, piriformis syndrome and tarsal tunnel syndrome associated with lumbar degenerative disease].

OBJECTIVE: Sacroiliac joint (SIJ) dysfunction, piriformis syndrome (PFS) and tarsal tunnel syndrome (TTS) produce symptoms similar to lumbar degenerative disease (LDD). Patients who have these diseases plus LDD sometimes experience residual symptoms after surgery for LDD. We therefore assessed the results of treatment of SIJ dysfunction, PFS and TTS associated with LDD. PATIENTS AND METHODS: We assessed 25 patients who underwent surgery for LDD and were affected with SIJ dysfunction (12 patients), PFS (7 patients) or TTS (6 patients). SIJ dysfunction was treated with rest, drugs, pelvic band and sacroiliac joint block. PFS was treated with rest, drugs, physical exercise, injection of local anesthetic into the piriformis muscle, and surgical resection of the piriformis muscle. TTS was treated with drugs and tarsal tunnel opening. We analyzed the improvement score and recovery rate (JOA score) for both LDD surgery and the treatment of SIJ dysfunction, PFS and TTS. RESULTS: Symptom improvement was observed in all patients with SIJ dysfunction and PFS and in 4 patients with TTS. The improvement score and recovery rate of treatments for SIJ dysfunction, PFS and TTS were lower than those of surgery for LDD. CONCLUSION: The improvement score and recovery rate of treatment for SIJ dysfunction, PFS and TTS were not as high as those for LDD. To enhance patient satisfaction, it is important to consider these complicating diseases when designing treatments for LDD.

Rash, Radiculopathy, and Cognitive Biases.

BACKGROUND: Physicians rely on intuition and pattern recognition to rapidly evaluate and treat patients. While the realities of our medical system require liberal use of these heuristics to efficiently make clinical decisions, such thinking patterns are error-prone-leaving the clinician at the whims of their cognitive biases.CASE REPORT: We describe a case of Lyme disease in which a pilot's rash and radicular pain were misdiagnosed on two separate occasions until, nearly a month after initially seeking medical care, the pilot was appropriately diagnosed and treated.DISCUSSION: This case highlights Lyme disease's mimicry of other common diseases and underscores the need to use slower, more deliberate evaluation in conjunction with pattern recognition and intuition to provide optimal care to flyers.Saul S, Tanael M. Rash, radiculopathy, and cognitive biases. Aerosp Med Hum Perform. 2019; 90(7):652-654.

The absence of piriformis muscle, combined muscular fusion, and neurovascular variation in the gluteal region

The gluteal region contains important neurovascular and muscular structures with diverse clinical and surgical implications. This paper aims to describe and discuss the clinical importance of a unique variation involving not only the piriformis, gluteus medius, gluteus minimus, obturator internus, and superior gemellus muscles, but also the superior gluteal neurovascular bundle, and sciatic nerve. A routine dissection of a right hemipelvis and its gluteal region of a male cadaver fixed in 10% formalin was performed. During dissection, it was observed a rare presentation of the absence of the piriformis muscle, associated with a tendon fusion between gluteus and obturator internus, and a fusion between gluteus minimus and superior gemellus muscles, along with an unusual topography with the sciatic nerve, which passed through these group of fused muscles. This rare variation stands out with clinical manifestations that are not fully established. Knowing this anatomy is essential to avoid surgical iatrogeny.

Ischiofemoral Impingement and Hamstring Syndrome as Causes of Posterior Hip Pain: Where Do We Go Next?

Recent advances in understanding hip joint anatomy and biomechanics have contributed to improvement of diagnosis and treatment decisions for distal causes of deep gluteal syndrome (DGS). Ischiofemoral impingement and hamstrings syndrome are sources of posterior hip pain that can simulate symptoms of DGS. The combination of a comprehensive history and physical examination with imaging and ancillary testing are critical for diagnosis. Six key physical examination tests are described to differentiate distal versus proximal sources of extrapelvic posterior hip pain. Outcomes depend on patient compliance and the understanding of the entire anatomy, biomechanics, clinical presentation, and open versus endoscopic treatment options.

Bilateral piriformis syndrome in two elite soccer players: Report of two cases.

Piriformis syndrome, a relatively rare condition, is described as entrapment of a sciatic nerve at the level of the piriformis muscle. There have been a few reports of bilateral piriformis syndrome in literature. In this study, we present bilateral piriformis syndrome in two professional soccer players from different teams who are symptom free at last follow-up after surgery. In both patients, resting EMG records were read normal, however EMG recording during the activity revealed prolonged H-reflexes. Both patients had no relief from conservative treatment and rehabilitation, therefore surgical treatment was performed. Preoperative mean visual analogue scale (VAS) value was 7, and decreased to 3 at the sixth month follow-up visit and at the longer term follow-up, mean 85months (74-96) it was valued at 1. Both soccer players returned to their active sports lives in the sixth postoperative month. According to Benson's functional evaluation scale, in long-term follow-up, there have been excellent results and both patients resumed their professional carrier for many years (mean 7 years).

Piriformis syndrome: treatment of a rare cause of posterior hip pain with fluoroscopic-guided injection.

INTRODUCTION: Piriformis syndrome involves the irritation of the piriformis muscle due to various reasons that are primarily related to anatomical variation or sciatic nerve compression due to contraction caused by overuse. In this study, we aimed to define an injection method that is easy to apply, safe, simple and repeatable. MATERIALS AND METHODS: We administered percutaneous lidocaine and depomedrol injections into the hips of 28 patients (14 men and 14 women) under fluoroscopic control. Bipolar injections of the piriformis muscle were performed at the medial pole, the intersection of the sciatic notch and the sacroiliac joint, and at the lateral pole of the femoral insertion region. Each injection was 5 cc, and the contrast agent was observed after the dyeing process. RESULTS: Clinical examinations were performed before and 6 weeks after the injections. The average of Harris Hip Score increased from a pre-injection score of 44.5 to a post-injection score of 68.5, and the Visual Analog Scale scores decreased from 8.3 to 4.2 (p<0.05). COMMENTS: Our findings lead to the conclusion that fluoroscopy-guided percutaneous local anaesthetic and corticosteroid injection is a simple and effective piriformis syndrome treatment that can feasibly be effectively performed by orthopaedic surgeons.

Bilateral variant hamstring musculature with unilateral variant sciatic nerve

Anatomic variation of lower limb innervation and musculature significantly impacts the structure and function of nearby musculature and vasculature. This case report details the findings of a rare unilateral sciatic nerve variation, as well as bilateral muscular slips within the lower limbs. The left sciatic nerve was found to emerge as its common peroneal and tibial divisions at the superior and inferior borders of the piriformis, respectively. The muscular slips were found to extend from the long head of the biceps femoris to the semitendinosus muscles bilaterally. Research suggests that the presence of sciatic nerve variation and accessory muscular slips within the same subject is an uncommon finding. These findings are significant due to their potential implications in both surgical and clinical specialties. Surgeons should be aware of anatomical variation in the gluteal and hamstring regions for procedures such as total hip replacements, while clinicians should be aware of such variation for diagnostic and nerve block purposes

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Piriformis syndrome: a case with non-discogenic sciatalgia.

Piriformis syndrome is a clinical picture of non-discogenic sciatica caused by compression of the sciatic nerve by the piriformis muscle. It has variable etiologies and the patho-physiology is not fully understood. The major etiology was known to be the spasm, edema and inflammation of the piriformis muscle and sciatic nerve compression of the muscle later on. Patients can be diagnosed immediately with a comprehensive clinical examination and early diagnosis makes the treatment much easier. Diagnosis of the piriformis syndrome, a very rare cause of low back pain, first requires that this syndrome is remembered, and then a differential diagnosis should be performed. A case of piriformis syndrome diagnosed in a patient who presented with low back pain is reported in this study.