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Piriformis muscle injection guided by sciatic nerve stimulation: Quick, simple, and safe technique

  • M. Mayo-Moldes EMAIL logo , A. Carregal , M. Corujeira , T. Fernandez und V. Vilanova
Veröffentlicht/Copyright: 1. Juli 2012
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Scandinavian Journal of Pain
Aus der Zeitschrift Scandinavian Journal of Pain Band 3 Heft 3

To the Editor,

The Piriformis syndrome (PS) is thought to involve the piriformis muscle because of its proximity to the sciatic nerve. This muscle follows a linear path coinciding with the sciatic nerve which lies beneath the muscle in the parasacral region [1].

PS is associated with buttock, hip and lower limb pain. Medical treatment that has been applied includes therapeutic stretching, ultrasound, massage, oral analgesics and intramuscular local anesthetic with or without steroid injections [2].

There is not a universally accepted technique for injection of the piriformis muscle. Several authors have reported imaging-guided injection techniques with fluoroscopy or CT that may not be available in most pain management centers [3,4]. Nowadays, ultrasound has shown promise for pain. However, the technique requires some experience before it can be performed by one operator also handling the needle [5,6].

We investigated whether local anesthetic nerve-stimulator guided injections are effective in achieving long-lasting pain relief in (PS) because the nerve stimulation is widely available, radiation free and easy to use.

Weprospectively enrolled 100 patients diagnosed of PS. All subjects complained of buttock, hip and lower limb pain for 3 months duration before admission to the study and all of them were refractory to conservative management measures. Pain was aggravated by sitting, stair climbing, and leg crossing. Subjects were excluded if imaging studies demonstrated evidence of a herniated lumbar disk or nerve root impingement, or electromyography examination demonstrated pathology proximal to the sciatic.

We use standard surface landmarks for the posterior approach to sciatic blockade. (After a skin wheal of local anesthetic), a 21G × 100 mm Stimuplex needle (Pajunk) was inserted perpendicular to the skin and advanced with an initial setting of 1.5 mA, 2 Hz. The sciatic nerve is identified by a reduction of frank gluteal contraction and plantar flexion/dorsiflexion response at a current of 1mA. We then retract the needle till extinction of the response.

Two patients did not meet our study criteria, and four patients refused to participate. Thus, 94 patients (70 females and 24 males) were enrolled in the study after applying exclusion criteria. The average age of the patients was 50 years. A perisciatic injection of local anesthetic using a nerve stimulator to locate and inject near the sciatic nerve and into the piriformis muscle was performed. All patients received 10 ml bupivacaine 0.125% without addition of steroids and were clinically evaluated at 1 and 4 weeks after the procedure. The visual analogue scale (VAS) was used to evaluate treatment response (VAS: 0 = no pain; 100 = worst possible pain). Prior to data analysis, improvement greater than 25mmon the VAS score was selected as clinically significant.

Data are shown as the mean ± standard deviations. Data were evaluated using paired t test. P < 0.05 was required for significance. We used SPSS 11 (SPSS Inc., Chicago, IL) for data analysis.

There was a statistically significant reduction in mean VAS scoring for buttock and hip pain at week 1 (84%) and week 4 (70%) (Fig. 1) and the pain was improved from 66.5±16.1mmto 32.8±27.3mm at the 4-week follow-up visit. 70% of patients experienced full recovery and were discharged from the Pain clinic, after 3 months, when pain was mild (VAS <30 mm).

Fig. 1 Pain, documented by the visual analogue scale (VAS). Data are presented as median, interquartile range; *P < 0.05, significant difference compared with baseline.
Fig. 1

Pain, documented by the visual analogue scale (VAS). Data are presented as median, interquartile range; *P < 0.05, significant difference compared with baseline.

Piriformis muscle depth measured with the needle was a mean of 6.7 ± 1.3 cm.

Our study shows that a perisciatic injection using simple landmarks and utilizing a nerve stimulator to locate and inject near the sciatic nerve and into the piriformis muscle is a quick, simple, economical and effective technique and can be considered an alternative to infiltration guided by fluoroscopy or CT.

DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2012.05.072.

Servicio de Anestesia, Hospital Meixoeiro, Complexo Hospitalario Universitario de Vigo, Meixoeiro sn, 36200 Vigo-Pontevedra, Spain. Tel.: +34 986811772.

☆This research was presented as a poster discussion at the “Pain In Europe”, 7th Congress of the European Federation of IASP Chapters (EFIC) 2011 in Hamburg, Germany, September 22, 2011.

  1. Conflicts of interest: None of the authors have conflicts of interest to declare.

References

[1] Benzon HT, Katz JA, Benzon HA, Iqbal MS. Piriformis syndrome: anatomic considerations, a new injection technique, and a review of the literature. Anesthesiology 2003;98:1442–8.Suche in Google Scholar

[2] Fishman LM, Anderson C, Rosner B. Botox and physical therapy in the treatment of piriformis syndrome. Am J Phys Med Rehabil 2002;81: 936–42.Suche in Google Scholar

[3] Fishman SM, Caneris OA, Bandman TB, Audette JF, Borsook D. Injection of the piriformis muscle by fluoroscopic and electromyographic guidance. Reg Anesth Pain Med 1998;23:554–9.Suche in Google Scholar

[4] Betts A. Combined fluoroscopic and nerve stimulator technique for injection of the piriformis muscle. Pain Phys 2004;7: 279–81.Suche in Google Scholar

[5] Smith J, Hurdle MF, Locketz AJ, Wisniewski SJ. Ultrasound-guided piriformis injection: technique description and verification. Arch Phys Med Rehabil 2006;87:1664–7.Suche in Google Scholar

[6] Peng PW, Narouze S. Ultrasound-guided interventional procedures in pain medicine: a review of anatomy, sonoanatomy, and procedures: part I: nonaxial structures. Reg Anesth Pain Med 2009;34: 458–74.Suche in Google Scholar
Published Online: 2012-07-01
Published in Print: 2012-07-01

© 2012 Scandinavian Association for the Study of Pain

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https://doi.org/10.1016/j.sjpain.2012.03.001

Artikel in diesem Heft

  1. Editorial comment
  2. Spontaneous pain is reduced by conditioning pain modulation in peripheral neuropathy but not in fibromyalgia—Implications for different pain mechanisms
  3. Clinical pain research
  4. Differential pain modulation in patients with peripheral neuropathic pain and fibromyalgia
  5. Editorial comment
  6. Pulsed radiofrequency—Time for a clinical pause and more science
  7. Clinical pain research
  8. Pulsed radiofrequency in peripheral posttraumatic neuropathic pain: A double blind sham controlled randomized clinical trial
  9. Editorial comment
  10. Phantom pains and sensations – how does it feel? Only the patient really knows
  11. Clinical pain research
  12. Phantom phenomena – Their perceived qualities and consequences from the patient’s perspective
  13. Editorial comment
  14. Impact of mental stressor on conditioned pain modulation
  15. Original experimental
  16. The effect of a mental stressor on conditioned pain modulation in healthy subjects
  17. Editorial comment
  18. Pharmacological modulation of chronic pain after whiplash injury
  19. Clinical pain research
  20. Whiplash Associated Disorders (WAD): Responses to pharmacological challenges and psychometric tests
  21. Editorial comment
  22. Why are autonomic responses to pressure pain different from those to heat pain and ischaemic pain?
  23. Original experimental
  24. Cardiovascular responses to and modulation of pressure pain sensitivity in normotensive, pain-free women
  25. Correspondence
  26. Piriformis muscle injection guided by sciatic nerve stimulation: Quick, simple, and safe technique
  27. Correspondence
  28. Musculus piriformis syndrome: Localization and injection therapy—Comment to letter from Mayo-Moldes M et al. [1]
  29. Abstracts
  30. The “pain matrix” reloaded
  31. Abstracts
  32. Endpoints in animal pain models
  33. Abstracts
  34. Evaluating pain-related behavior in spinal cord injury
  35. Abstracts
  36. The role of the amygdala in sensory and emotional-like pain behavior in neuropathic animals
  37. Abstracts
  38. Peripheral and central pain mechanisms—From animal models to clinical research
  39. Abstracts
  40. Human experimental models of central sensitization—Do they bridge the gap between animal models and clinical observations?
  41. Abstracts
  42. Assessment of central sensitization in the clinic. Is it possible?
  43. Abstracts
  44. Migraine neurobiology and treatment
  45. Abstracts
  46. Chronic headaches–Goals and obstacles
  47. Abstracts
  48. Trigeminal neuralgia and other cranial neuralgias
  49. Abstracts
  50. Temporomandibular disorders: Pathophysiology and diagnosis
  51. Abstracts
  52. HIV-associated painful polyneuropathy
  53. Abstracts
  54. Keynote: Neuronal and glial signalling in pain neuroplasticity
  55. Abstracts
  56. Neuropathic pain—From guidelines to clinical practice
  57. Abstracts
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  59. Abstracts
  60. NSAIDs in postoperative pain
  61. Abstracts
  62. How should we prevent persistent postoperative pain?
  63. Abstracts
  64. Opioids: Genetics and receptors
  65. Abstracts
  66. Chronic pain and sleep disorders
  67. Abstracts
  68. Population-based studies on chronic pain: The role of opioids
  69. Abstracts
  70. Living beyond pain: Acceptance and commitment therapy
  71. Abstracts
  72. Modality specific alterations of esophageal sensitivity caused by longstanding diabetes mellitus
  73. Abstracts
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  75. Abstracts
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  77. Abstracts
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  83. Abstracts
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  85. Abstracts
  86. Pain prevalence in a university hospital in Iceland
  87. Abstracts
  88. The effect of tail-docking neonate piglets on ATF-3 and NR2B immunoreactivity in coccygeal dorsal root ganglia and spinal cord dorsal horn neurons: Preliminary data
  89. Abstracts
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  91. Abstracts
  92. Glutamate attenuates nitric oxide release from isolated trigeminal ganglion satellite glial cells
  93. Abstracts
  94. Acute behavioural responses to tail docking in piglets – Effects of increasing docking length?
  95. Abstracts
  96. Dose and administration-period play a key role in the effect of ceftriaxone on neuropathic pain in CCI-operated rats
  97. Abstracts
  98. Translational aspects of rectal evoked potentials: A comparative study in rats and humans
  99. Abstracts
  100. Time-course of analgesic effects of botulinum neurotoxin type A (BoNTA) on human experimental model of pain induced by injection of glutamate into temporalis muscle
  101. Abstracts
  102. The effect of nerve compression and capsaicin on contact heat evoked potentials (CHEPs) related to Aδ and C fibers
  103. Abstracts
  104. Effect of specific trapezius exercises vs. coordination training on corticomotor control of neck muscles
  105. Abstracts
  106. SNP in TNFα T308G is predictive for persistent postoperative pain following inguinal hernia surgery
  107. Abstracts
  108. Chronic pain in thoracotomy
  109. Abstracts
  110. The variability in thermal threshold-assessments in post-thoracotomy pain syndrome
  111. Abstracts
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  113. Abstracts
  114. Neuroplastic alterations in brain responses to painful visceral stimulations reflects individual neuropathic symptoms in diabetes mellitus patients
  115. Abstracts
  116. Exercise and conditioned pain modulation have different effects on cuff pressure pain tolerance in humans
  117. Abstracts
  118. Hyperalgesia in human skin and deep-tissues inside and outside of a UVB irradiated area
  119. Abstracts
  120. Effect of experimental jaw muscle pain on bite force during mastication
  121. Abstracts
  122. Reflex threshold assessment methodology for evaluation of central sensitisation is vulnerable to EMG crosstalk
  123. Abstracts
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  125. Abstracts
  126. Influence of emotionally loaded visual and gustatory stimuli on pain perception
  127. Abstracts
  128. Modulating pain with augmented reality
  129. Abstracts
  130. Offset analgesia: A reproducibility study
  131. Abstracts
  132. Visualization of painful process in peripheral tissue using positron emission tomography and [11C]-D-deprenyl
  133. Abstracts
  134. Mirror-image sensory dysfunction in the post-thoracotomy pain syndrome
  135. Abstracts
  136. Genetic variation in opioid receptor genes and sensitivity to experimental pain in male and female healthy volunteers
  137. Abstracts
  138. Mechanical sensitivity in migraine patients during attack, remission, and pain-free periods:A preliminary study
  139. Abstracts
  140. Multivariate pattern analysis of evoked brain potentials by temporal matching pursuit and support vector machine
  141. Abstracts
  142. Pain following stroke: A prospective study
  143. Abstracts
  144. Chronic thoracic pain in children after cardiac surgery
  145. Abstracts
  146. Chronic pain after breast augmentation is associated with both signs of peripheral nerve injury and central nervous mechanisms
  147. Abstracts
  148. Sensory phenotypes in patients with peripheral neuropathic pain evaluated with quantitative sensory testing
  149. Abstracts
  150. Is health related quality of life related to the pattern of chronic pain?
  151. Abstracts
  152. Comparison between ropivacaine local infiltration analgesia with ketorolac or placebo for total knee replacement surgery
  153. Abstracts
  154. Treatment with topical capsaicin: Experience from a pain clinic
  155. Abstracts
  156. Distribution of concussion related symptoms after whiplash injury in risk strata
  157. Abstracts
  158. HIV/AIDS in different cultures
  159. Abstracts
  160. Pain perception is altered in patients with medication-overuse headache but can improve after detoxification
  161. Abstracts
  162. Detoxification in a structured programme is effective for medication-overuse headache
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