Piriformis syndrome (PS) is an elusive, benign medical condition. Patients usually complaint deep-seated gluteal pain with some aggravating and relieving factors. Regarding aggravating factors, prolonged sitting on the affected side, affected side lying, posture change - standing from sitting, forward bending, etc. are common, whereas walking relives pain somewhat, especially in chronic cases. In acute PS, patients have pain relieving posture finding difficulty, physicians also get confused it with more prevalent low back pain diagnosis, namely prolapsed lumbar intervertebral disc (PLID).
PS is a disorder of exclusion of clinical mimics and it has no definite cause; in literature, lumbar spinal stenosis, leg-length inequality, professional dancers, fibromyalgia, previous fall, blunt gluteal trauma, etc. are mentioned as its risk factors. Sporadic case reports and our recent systematic review addressed infective cause of piriformis muscle injury, where patients complain of clinical features unlike of PS. In piriformis muscle (PM) infection, patients report of persistent deep gluteal pain that doesn't change with posture, patients also have fever and raised laboratory inflammatory markers (raised WBC count, ESR & CRP). Moreover, there may be characteristic MRI changes in the deep-seated gluteal and pelvic structures including PM. Pain medications & PM stretching exercise don't help patient anyway, they need antimicrobials as well; when antibiotics don't work, surgical drainage of PM is required. Like in PS, intra-lesional steroid is contraindicated here. If piriformis pyomyositis is left undiagnosed and untreated precisely, life-threatening consequences may be the outcomes, hence we can consider the piriformis pyomyositis as the PM emergency.
What do you think?
Suggested reading :
1. Siddiq AB, Danny Clegg, Hasan SA, Rasker JJ. Extra-spinal sciatica and sciatica mimics – a scoping review. Korean J Pain 2020; 33:305-317.
2. Siddiq AB, Rasker JJ. Piriformis pyomyositis, a cause of piriformis syndrome – A systematic search and review. Clin Rheumatol 2019; 38:1811-1821.
Hi,could you be a lilte bit more specific ? Is it a biomechanical issue ? Infectious ? Neurological ? Oncologic ? Trauma ? Pain ? etc.
Good summary of condition.
Septic myositis is a medical emergency.
In my opinion, should be considered as a piriformis muscle (PM) emergency, a Piriformis pyomyositis. However, in the diagnosis of PM, we have not to neglected clunealgia too. Then, every clinician has to see if there is a trauma, or neurologic symptoms, or acute pain, or an oncological issue post prostate cancer.
Sergio Marcucci, PS features have two components - (1) features related to piriformis muscle (PM) spasm, and (2) features alike sciatica because of irritation of the sciatic nerve (SN) by adjacent spasmodic PM. PM dominating features include deep-seated gluteal pain aggravating on the affected side sitting, forward bending, squatting, and changing body postures (for example, standing from sitting); however, when spasmodic PM irritates SN vicinity, alongside patients' also complain about radiating gluteal pain according to SN course with a tingling sensation and subjective heaviness of the ipsilateral lower extremity. My point is that, if PS patients have sciatica-like feature because of irritation of SN from spasmodic PM, then only you can get confused with clunealgia, not otherwise. So, we should get cautious of which one's feature is predominating - PM spasm or PM irritating SN adjacent or both. We should also remember - PS features are fluctuating, its features are not consistent.
PM involvement in the prostate or any other malignancy may lead to features alike PS; AND situation like this, diagnosis and treatment of malignancy invading PM is more important than mere treating PS complication of the respective cancer.
Thank you.
Jean-Marc Valiadis, we're talking about piriformis muscle infection.
Piriformis pyomyositis, and do not forget to consider clunealgia or pelvic-sacrum trauma, oncologic issues after prostate cancer.
Well, we open the "deep tissues infection management" book then. It depends on various factors ( anamnesis, pre-conditions, etiology+++, severity+++, progression+++, imagery and biology) can be treaded by initial broadspectrum ATB (after hemocs */- drainage or surgery sampling) +/- CT assisted drainage +/- surgery +/- salvage surgery +/- adapted ATB. Surgery option should be assessed ASAP and not when ATB failled. This unusual location is a red flag. Where do you go with this ? Is it a case study ?
@ Md Abu Bakar Siddiq, I absolutely agree with your statement on PS features and the rest of your comment. In my comment, I talked about clunealgia because PS can induce an over contraction of the gluteus muscles and irritate the cluneal nerves.
Thank you
Apart from the infectious problems, already described and warned, the "pseudo-sciatica" due to lesions of the piriformis,
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