Piriformis Syndrome

Piriformis Syndrome Overview

The piriformis muscle is a very small muscle located in the buttocks region and is found in close approximation to the sciatic nerve. Years ago, cadaver dissections revealed the close approximation of the sciatic nerve and the piriformis muscle. Clinicians at that time did not have the knowledge that leg pain originates from spinal nerve compression caused by bone spurs and disc herniations in the spinal canal.

70 years ago, it made sense for clinicians to draw the conclusion that the piriformis muscle could compress the sciatic nerve. During dissection of cadavers, the clinicians found that 3-5% of sciatic nerves were found to travel directly through this muscle and about 1-2% of the general population developed leg pain.

Fortunately, the discoveries of nerve compression in the spine in the twentieth century by Mixter and Barr dispelled the notion that piriformis syndrome is the cause of sciatica. Unfortunately, piriformis syndrome became so popular that this diagnosis still continues as a diagnosis of leg pain to this day. This is due to two separate associations.

First, the onset of sciatic nerve pain due to spinal nerve compression starts in the buttocks right around the piriformis muscle. This association of the location of the sciatic nerve and the onset of local pain is tempting to then blame the unfortunate piriformis muscle as the cause of this nerve pain.

The other unfortunate association is that tenderness (using fingers to palpate this region) around the piriformis muscle will also elicit pain down the nerve. This is due to the fact that compression of the nerve in the spine due to disc herniation will make the entire nerve sensitive in certain individuals. This sensitivity can be found not only in the region of the piriformis muscle but also in the back of the knee. The close approximation of this tenderness and sciatica makes certain clinicians accept the diagnosis of piriformis syndrome to this day.

Are you suffering from nerve pain associated with piriformis syndrome?

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(Please keep reading below for more information on this condition.)

The “Cure” and Diagnosis of Piriformis Syndrome

The “cure” for piriformis syndrome is to find the cause of the nerve pain. This typically will be a good physical examination and identification of the spinal nerve root responsible for the radiation of pain. X-rays and MRI evaluations are part of the diagnostic testing. Finally, if there is any doubt of the origin of pain, a selective nerve root block (see website) can be diagnostic.

Does piriformis syndrome really exist? The answer is yes but it is an extremely rare condition. In 30 years of practice, I have seen this syndrome twice. If every other cause of nerve pain has been ruled out and the only potential cause left is piriformis syndrome, then this diagnosis can be looked into.

The diagnosis is made by again by first ruling out every other type of nerve disorder. Only after that, provocation of the piriformis muscle can be induced by stretching this muscle. If sciatic nerve symptoms are evoked by this maneuver, consideration of the diagnosis of piriformis syndrome can be entertained.

The piriformis muscle’s action when contracting is to externally rotate the hip. Therefore, the piriformis muscle is stretched (tightened) by internally rotating the hip. Hip internal rotation with flexion while the patient is supine (lying on their back) will reproduce buttocks and leg pain if piriformis syndrome is present.

Conformation is made by a local injection of anesthetic (Lidocaine) and steroid performed under ultrasound guidance with good relief of symptoms. This injection can also yield long-term relief of symptoms.

If the patient has confirmed piriformis syndrome and had failed all the other therapies, a surgical release of this muscle can give long-term relief.

I have yet to consider a patient for this type of surgery.

For more resources on nerve pain and piriformis syndrome, please contact the office of Dr. Donald Corenman, spine specialist and back doctor in the Vail, Aspen, Denver and Grand Junction, Colorado area.

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Donald Corenman, MD, DC

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81 reviews

Eric S

Sep 26, 2021

by Eric S on Donald Corenman, MD, DC

Successful pars repair at 46 years old

Back in November of 2018 (at 46 years old) I came from Vancouver BC to have a pars repair done with Dr. Donald Corenman at the Steadman Clinic in Vail Colorado. I'm finally posting this review nearly three years later in late 2021. The reason I waited so long was I wanted to know the final result before I posted my review. Unfortunately in that time Dr. Corenman has retired. Nevertheless, I want to post this review of Dr. Corenman and his staff at the Steadman Clinic in their excellent treatment of my L5 pars interarticularis.

I fractured my pars at age 42 back in 2014 when rolling on the gym floor, and was denied treatment by the Canadian healthcare system, probably due to my age. First my GP told me there was no surgical option for a pars defect, which was quite incorrect! I tried to live with it, but the symptoms worsened (periodic random spine slippage and weeks of resultant pain after just bending over to tie my shoe, so I eventually learned to mostly squat and hardly bend). When I finally consulted with Canadian spine surgeons, I was told they believed my pars defect had been congenital (since birth). This was absurd, considering I had done extreme martial arts (including jiu jitsu) for years prior, as well as 5 years of reinforcing steel full time in my 20s, probably the hardest job on the back you can find. No pars defect like mine would possibly have allowed this--ergo it was impossible that I had had the defect since birth. I did however have an asymptomatic congenital spina bifida occulta that made me more susceptible to a pars fracture. In 2014 in one instant, I went from having the strongest back people I knew said they'd ever seen, to being unable to safely bend over and tie my shoe without a non-negligible risk of my spine slipping randomly (which would lead to weeks of pain after each occurrence). This was due to the unilateral L5 pars defect, otherwise known as spondylolysis. It was when lying in pain on the floor 4 years later after maybe the 6th spine slippage event post injury, that I had had enough, and resolved to have surgery. If Canada's "universal health care" said no, I would make lemonade from lemons, and find the very best surgeon in the world at pars repairs. That was Dr. Donald Corenman. Dr. Corenman back in 2018 ran a website https://neckandback.com/ that dedicated many pages to the science of every aspect of pars repairs, from eligibility (good discs on MRI), to best surgical techniques (minimal open compared to minimally invasive), best imaging to use (i.e., O-Arm with Stealth imaging vs. older fluoroscopy), the ideal amount of BMP to use and why not use too much or too little, and much more, all to do with pars repairs, pages upon pages of his site just on the pars, with scientific references and his own extensive expert opinion. As a health research statistician, I was very impressed with this. It was in stark contrast to the websites of other spine surgeons which barely gave the pars a word or two, focusing almost exclusively on fusions. I had found the best surgeon in the world for pars repairs, and so after Dr. Corenman personally screened my MRI to ensure my discs were healthy, I booked the surgery.

Being 46 years old at the time of surgery in 2018, with a 4-year-old pars fracture from 2014 combined with a congenital SBO meant my pars fragment was somewhat atrophied, but it was "very solid", said Dr. Corenman in the operative report. Nevertheless, it was challenging with two things to fix, the pars and SBO, and OR time was around 4 hours. Recovery over the following months was guided by a very clear "Spine binder" from the Steadman Clinic with strict rules of "no BLT" (no bending, lifting or twisting), and illustrated physiotherapy guidelines. They even warned patients to avoid fish oil supplements, which could excessively dampen inflammation and hence slow bone healing. They answered many questions I had during months of recovery, with responses coming from the very supportive Lori Fugate (then director of Dr. Corenman's practice), and Ehrich Bean (then physician's assistant at the practice), as well as a couple calls with Dr. Corenman himself after two of the CT scans. Ehrich Bean offered great advice for taking the spine binder conservatively due to the nature of pars repairs vs. fusions. The final post-op CT scan I had was a couple weeks ago at 34 months post-op, and Dr. Corenman had retired, but I got a very positive and informative call from Eric Strauch (current PA at the Steadman Clinic under Dr. Corenman's replacement there, and who had also worked with Dr. Corenman previously). The staff at the Steadman Clinic were extremely supportive all the way through the process. I should mention, the local Canadian spine surgeon did offer me very good post-operative support including antibiotics as needed to deal with a mild surface incision-site infection early on, booking numerous x-rays when I felt something was amiss, as well as booking all four of my post-op CT scans. I am very grateful for that support also.

My final result shows plenty of solid bone across the pars and a healed SBO, with my vertebral body now a solid bone ring instead of being broken at two places as it was pre-op. Does my spine hold up in the real world? You bet! I have recently dug and moved several yards of dirt and sand and gravel by myself (shovel and wheelbarrow!) to fix our water main, pulled roots from the yard, moved several "portable" (these are HUGE) air conditioners up several flights of stairs my myself, and lifted weights. I now run 2 miles (3.2 KM) several times weekly with a hard 100 meter dash in the middle. I bend deeply before each run I go on, with no spine slippage. My spine feels amazing. I can bend over to do exercise, or real word tasks, with no risk of spine slippage.

My sincere thanks to God, Dr. Donald Corenman, Lori Fugate, Ehrich Bean, Eric Strauch, and the Steadman Clinic, as well as the Canadian spine surgeon who offered me excellent post-operative care back in Canada. You have all given me a new lease on life.

Sincerely,
Eric S

Robert S

May 11, 2021

by Robert S on Donald Corenman, MD, DC

Back Fusion Surgery

I had my entire lumbar spine fused in November of 2018. I had scoliosis , with pinched nerves that were so painful I could hardly walk - and standing for more than a few minutes was impossible. Even sitting was painful.
The fusion surgery produced immediate relief! And the recovery was much easier than I expected.
To this day I can do all the activities I love from hiking, to standing in a stream fly fishing to riding my bike long distances - or just walking down the street with my wife.
Kudos to Dr. Corenman and his staff, (including the two Erics) for taking such good care of me!

Leslie R

Jul 9, 2020

by Leslie R on Donald Corenman, MD, DC

TLIF

I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. I was always treated with respect and explained everything throughly, that made it easy for everyone to understand. I highly recommend Dr. Corenman and the Steadman Clinic.

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