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Piriformis Story

The Piriformis Syndrome seems still considered “controversial” with a small group of followers and, it seems, a far larger group of non-believers.  My own experience began in this way:

As the young doctor in the west of Wales I often encountered coalminers with back pain and sciatica.  One had a clear history – he had fallen back onto the the sharp corner of a metal scuttle used to carry coal which struck him in the buttock.  He was clear that his persisting symptoms began at that moment. It seemed that he had a focal injury in the buttock affecting the sciatic nerve trunk and the nerve was trapped in the buttock, not by a disc in the back.

The consultant surgeon was adamant that this was a nerve root entrapment by pressure from a disc.   In the early 60’s the dynasty of the disc was accelerating its momentum, but precision in diagnosis was notably poor.  All that was available was the myelogram, which like many medical endeavours could only assist by negativities.  The ” exploratory” surgery on the disc was not beneficial and I continued to think about the outcome with regret. 

In 1980 a man in his early 30’s walked into my office. “I don’t know why I am here,” he said “but I was passing, saw your name and took a chance”. 

He had had three laminectomies by a professor of neurosurgery at a teaching hospital and now was being told to “live with the pain”.  That morning he had resigned his job. “I didn’t have the energy to get up and walk across to the filing cabinet”.  He had sold his house at a  desirable beach location, because  pain prevented him climbing the stairs to the car park. 

His pain was located precisely over the piriformis in his buttock and he had a notably sensitive sciatic nerve when felt rectallyPalpating the nerve in the buttock duplicated his symptoms. His replicated the Welsh miner.

“A new machine has been installed in the city” I said “it is called a computerized tomogram”. 

He looked blank.  I welcomed the chance of testing this machine.

This was the scan, which showed an enlarged piriformis muscle in all cuts.

mcculloch-painted-compressed

The piriformis is red, the sciatic nerve blue

“I have had so many opinions”, he said “which have all been wrong.  I am sure you will understand if I take the scan and ask for a further opinion.”

He had a  contact with another professor of neurosurgery who, as it happened, was hosting an international neurosurgical conference that week.  The scan was presented at the conference.  The opinion of the meeting was universal: “This is not the cause of your problems.  We advise you to stay away from further surgery.”

He returned despondently.

“You can’t continue through life as matters are.” I said

“I suggest that I release the piriformis muscle. There is minimal downside, and the potential to make your life worth living again”.  He nodded in dumb acceptance. 

The procedure was photographed, and later that day the photographer boasted  that he had seen a man who “was going to have a big pain in his behind!”  The woman to whom he was talking responded “No he is not. He is my boyfriend and he has no pain”.

A week or so later Mac did a charity walk of some kilometers without pain for the first time in years and, as far as I am aware, he never again had pain.

As I had mainly spinal practice persons with piriformis entrapment appeared from time to time.  However precession in diagnostic accuracy was a concern, since it soon became clear that CT alone, and ultimately MRI alone, could not provide an unequivocal diagnoses.  What was helpful was to paralyze the piriformis with a local anaesthetic. Initially this was done blindly by advancing a needle a centimeter or so from the lateral edge of the sacrum.  This usually gave persuasive diagnostic information by abolishing the pain for the duration of anaesthetic effect.  But it did not give the certain anatomical precision which I would have liked.  Later  I began injecting the piriformis under CT guidance and this technique became widely adopted, and spread widely internationally.

Skepticism remained.  At that time access to literature was difficult and I could find no previous experience with the entity.  Some years later I discovered that a description from Durban, South Africa, from about 1947  by, as I remember it, a Dr Adams. A neurosurgeon once asked me where he could find the literature on Piriformis Syndrome.  I said that I did not know of any literature but I could explain to him my experiences.  He said that he was not interested in my opinion and put the phone down.

I have had three failures following piriformis release, each of which, in retrospect, could be explained as failures in selection.  Nevertheless, the procedures were relatively innocuous, and had, as far as I am aware, no downside.  Balanced against that were a great number of successes.

 [A discussion on the etiology of this syndrome will be addressed in another paper.]

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