A minimally invasive open surgical approach for piriformis syndrome. A case report and literature review

Abstract

Piriformis syndrome is being increasingly recognized as a distinct clinical entity which is now thought to account for as many as 6–8% of cases of lumbar backache and sciatica. Gender distribution notes a strong female predominate with a female to male ratio of 6:1.4. The disease is noted to occur as a primary form as well as a secondary form with a wide differential diagnosis. Diagnosing the problem as the cause of a patient’s pain is difficult and the standard clinical tests have a low sensitivity. MRI evaluation is problematic due to thickness assessment alone being of limited value. Ultrasonography has shown promise and demonstrated superiority to MRI evaluation due to its ability to assess cross sectional area and inflammatory changes in the sciatic nerve. Management necessitates a conservative 6-week trial of non-steroidal anti-inflammatory medication, muscle relaxants, physical therapy and steroid injections. Most patients respond to this conservative regimen within 1–3 weeks however for enduring relief adherence to a stretching exercise program cannot be over-emphasised. Surgery is considered a last line resort and the standard approach utilizes a 12 cm incision placed posterior to the greater trochanter through which division of the piriformis tendon and a neurolysis of the sciatic nerve from the piriformis muscle belly is achieved. We report an adult female patient with piriformis syndrome who failed a 6-week trial of conservative measures. She was taken to the operating room and through a minimally invasive open surgical approach utilizing a 6 cm skin incision posterior to the greater trochanter the surgical objectives were achieved. There were no complications and at her 6-week follow-up appointment she was pain free. We recommend a minimally invasive open approach, through a 6 cm skin incision placed posterior to the greater trochanter, as adequate to achieve the surgical objectives in the surgical management of this disease.