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Open Surgical Decompression for Piriformis Syndrome

March 01, 2020

Contributors: David A Bloom, BA; Dylan Lowe, MD; Robert J Meislin, MD, FAAOS; Jonathan M Vigdorchik, MD, FAAOS; David Klein, DO

Piriformis syndrome is a relatively rare cause of posterior buttock and hip pain and is diagnosed clinically. In diagnosing piriformis syndrome, surgeons must rule out lumbar radiculopathy, ischiofemoral impingement, gluteus or hamstring strain, and intrinsic and extrinsic sciatic nerve lesions. The sciatic nerve runs under the piriformis muscle, and a hypertrophic piriformis may place pressure on the sciatic nerve. Management of piriformis syndrome consists of an initial course of nonsurgical treatment, including physical therapy, the use of NSAIDs, and Botox injection. In general, surgical decompression is reserved for patients with piriformis syndrome refractory to nonsurgical management. This video demonstrates open surgical decompression in a middle-aged woman with piriformis syndrome. The video provides an overview of the pathogenesis, diagnosis, and management of piriformis syndrome, followed by the case presentation of a 48-year-old woman with 10 years of right-sided hip pain localized to the buttock and greater trochanter who has no history of trauma. The patient's pain has not improved with physical therapy and corticosteroid injections in the piriformis, the hip, and the trochanteric bursa; arthroscopic right hip labral repair; cam and pincer lesion resection; and iliopsoas release, which was performed 2 years ago. On physical examination, tenderness is noted at the ischium along the path of the piriformis tendon, at the hamstring insertion, and at the greater trochanter. Pain was reproduced with external rotation, and the patient was neurovascularly intact distally. Open surgical decompression was indicated in this patient. The video describes posterior facet reduction osteotomy of the greater trochanter for the management of trochanteric impingement, which often is performed in combination with surgical piriformis decompression. Postoperatively, the patient was allowed to partially bear weight with the use of crutches until the sutures were removed at a follow-up of 2 weeks. Physical therapy with weight bearing as tolerated was performed for 6 weeks. Open surgical decompression is a reliable option for the management of piriformis syndrome refractory to nonsurgical management and should only be considered after all nonsurgical treatment options have been exhausted. Although a few prospective studies are available on this topic, case series have demonstrated marked improvement in patient-reported outcome scores for patients with piriformis syndrome who undergo open surgical decompression.