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드디어 완성..
허리디스크로 인한 좌골신경 2차 압박(이중압궤증후군) 치료법
허리디스크로 신경근이 압박, 염증이 발생하여 과민해진 좌골신경은 엉덩이 이상근부위에서 2차 압박을 받을 수 있습니다. 이를 이중압궤증후군(double crush syndrome)이라고 합니다. 이로 인해 둔부, 하지 방사통이 악화되고 이 문제가 해결되지 않으면 환자는 하지 방사통으로 오랫동안 고통을 겪을 수 있습니다.
이중압궤증후군(double crush syndrome)은 신경의 유주 경로를 따라 2차 압박 병변(dual compressive lesions)이 동시에 존재하는 것을 말하는 일반적인 용어입니다. 이 용어는 1973 Upton and McComas에 의해 처음 제안되었는데, 척추신경(spinal nerves)과 팔의 말초신경(peripheral nerves)이 함께 포착되어 여러 가지 복합적인 임상 증상이 나타는 개념입니다. 즉 목 디스크로 신경근 압박이 있을 때 말초부위(손목 수근관)에서 2차압박이 나타날 수 있다는 뜻입니다.
이중압궤증후군을 연구한 논문에 의하면 2차압박이 나타나는 비율은 7-73%까지 다양하게 보고 되고 있습니다. 특히 남자가 여자에 비해 4배가량 많이 나타나고, 나이가 들수록 많이 나타납니다.
허리디스크를 치료하면서 디스크-신경근 유착을 떼기 위해 신경가동 기법을 시행하여 디스크-신경근 유착문제가 해결되었음에도 불구하고 하지 저림증이 지속되는 경우가 있습니다. 이는 이상근에서 좌골신경을 2차로 압박하기 때문인 경우가 대부분입니다.
이상근과 좌골신경의 유주는 다양한 변이(variation)가 있습니다. 이상근의 형태도 다양한 변이가 있고, 좌골신경도 다양한 변이가 있습니다. 이를 그림으로 살펴보면 다음과 같습니다. 이상근은 항상 짧아지려는 성질을 가진 자세유지근인 데다가, 이렇게 다양한 변이 때문에 흔하게 좌골신경을 2차압박 하여 하지 방사통을 악화시킬 수 있습니다.
그림. 좌골신경의 변이,
그림과 같이 좌골신경통을 호소하는 환자 중 11% 이상의 환자에서 이상근 사이로 좌골신경(sciatic nerve)이 지나갑니다. 그래서 허리디스크와 동반된 이중압궤(double crush)가 없이도 가끔 하지 저림증이 나타나는데 이를 이상근 증후군(piriformis syndrome)라고 합니다. 이상근 증후군의 진단은 하지 저림증이 지속되고 허리디스크가 없을 때 고려할 수 있습니다. 근전도 검사를 통해서 확진할 수 있습니다.
대개 허리디스크로 발생하는 이중압궤증후군으로 인한 하지 방사통의 지속을 막기 위해서는 허리디스크 초기부터 이상근부위에 따뜻한 찜질 10분 이상 실시 후 허혈성 압박, 이상근 강제스트레칭, 근에너지 기법 등을 이용하여 치료해야 합니다. 이렇게 명백한 근육통일 경우에 핫핵을 사용하면 좋습니다. 이론적으로 초음파, 단파 등의 전환열을 이용하여 이상근의 이완을 확실하게 시킬 수 있을 듯 합니다. 그런데 경험적으로 보면 테니스 공을 이용한 허혈성 압박, 이상근 강제스트레칭, 근에너지 기법을 이용한 근이완 기법이 더욱 효과적입니다.
사진. 이상근 강제스트레칭 방법 1. 누워서. 2. 반대로.
임상 사례에서 보면 이상근부위의 심한 압통이 해결되지 않고서는 하지 방사통, 하지 저림증은 잘 치료되지 않습니다. 환자들에게 이상근 허혈성 압박을 시키기 위해서 테니스 공을 이용하면 좋습니다. 테니스 공을 이용한 허혈성 압박은 간편하고 지속적으로 압박할 수 있기 때문에 임상에서 유용합니다.
사진. 테니스공으로 허혈성 압박하는 방법
근에너지 기법을 이용하여 이상근을 이완시키는 방법을 소개합니다. PIR 기법 3회, RI기법 1회를 하루 3차례 시행하면 이상근은 쉽게 이완되어 하지 방사통을 치료할 수 있습니다.
사진. 이상근 근에너지 기법(PIR).. RI기법
기억하십시오. 잘 호전되지 않는 하지 저림증이 있을 때 두 가지를 고려할 수 있습니다. 그중 한 가지가 디스크-신경근 유착에 의한 신경포착이고, 다른 한 가지가 이상근에 의한 좌골신경의 포착입니다. 이 두 가지를 잘 진단하고 치료하면 오랫동안 하지 저림증으로 고생하는 환자의 증상을 효과적으로 치료할 수 있습니다.
이상근아래에서 눌리는 경우
- 11% 이상의 환자에서 이상근근육 사이로 sciatic nerve가 지나갑니다. 그래서 허리디스크와 동반된 double crush가 없이도 가끔 이상근 증후군이 관찰됩니다.
- 대개 허리디스크와 double crush상태로 많이 나타나므로 급성 디스크로 인한 요통, 이상근 증후군이 발생했을때, 디스크가 탈출된 부위는 아이스팩을 1시간 30분 이상 하루 5회, 이상근은 핫팩, 허혈성압박, 이상근 자가이완법, 침치료, 근에너지기법 등을 이용하여 치료합니다. 경험적으로 이상근부위의 심한 압통이 해결되지 않고서는 하지 통증, 저림증은 해소되지 않습니다.
Lancet. 1973 Aug 18;2(7825):359-62.
The double crush in nerve entrapment syndromes.
=> 최초의 주장
힘들지만 먼저 논문 몇개를 읽어야 겠다.
Neurophysiological study to assess the severity of each site through the motor neuron fiber in entrapment neuropathy.
Shibuya R, Kawai H, Yamamoto K.
Department of Rehabilitation, Osaka Rosai Hospital, Sakai, Japan. shibuyar1@yahoo.co.jp.
ABSTRACT: BACKGROUND: The double crush hypothesis (DCH) that had been widely accepted seems to have been dismissed recently. Prior to the DCH, retrograde changes in the proximal median nerve in carpal tunnel syndrome (CTS) were reported. There has been no report of quantitative analyzing about the effect of one site's compression on another site all through the same peripheral nerve in CTS patients. METHODS: We measured the central motor conduction time (CMCT), motor conduction latency of the cervical root region (CRL), peripheral path latency from the rootlet to the wrist (PL) and motor distal latency (MDL) in the median nerve and ulnar nerves, respectively in CTS patients. RESULTS: MDL, PL and CRL were prolonged selectively in the median nerve, but not in the ulnar nerve of CTS patients. And in the median nerve measurement, MDL was high (r = 0.59, p < 0.0001) while PL showed a significant (r = -0.28, p < 0.05) relationship with CRL. MDL was large (r = 0.58, p < 0.0001) and showed a close (r = 0.59, p < 0.0001) relationship with the amplitude of CMAP. There was no significant difference between the amplitude of the normal CRL group and that of the prolonged CRL group. This quantitative analysis showed a linear relationship among MDL, CRL and CMAP amplitude. CONCLUSION: Dual entrapment lesions did not unexpectedly exaggerate the vulnerability or total damage. The vulnerability and the damage were proportional to the severity of each lesion. If the DCH term presented to an unexpectedly exaggerated degree, the cases of double crush symdrome in the CTS patients were rare, but if the term DCH refers to only this linear relationship, the DCH should not be dismissed.
[Diagnosis and therapy of cubital tunnel syndrome--state of the art]
[Article in German]
Assmus H, Antoniadis G, Bischoff C, Hoffmann R, Martini AK, Preissler P, Scheglmann K, Schwerdtfeger K, Wessels KD, Wüstner-Hofmann M.
Praxis für periphere Neurochirurgie, Dossenheim. hans-assmus@t-online.de
The cubital tunnel syndrome is one of the most widespread compression syndromes of a peripheral nerve. In German-speaking countries it is known as the sulcus ulnaris syndrome (retrocondylar groove syndrome), which is anatomically incorrect. The cubital tunnel consists of the retrocondylar groove, the cubital tunnel retinaculum (Lig. arcuatum or Osborne band), the humeroulnar arcade and the deep flexor/pronator aponeurosis. According to Sunderland it can be divided into a primary form (including the ulnar luxation and the epitrocheoanconaeus muscle) and a secondary form caused by deformation or other processes of the elbow joint. The diagnosis has to be confirmed by a thorough clinical examination and nerve conduction studies. Neurosonography and MRI are becoming more and more important with improving resolution and enable the direct identification of morphological changes. Differential diagnosis is essential in atypical cases, especially C8 syndrome and pressure palsy. Double crush (double compression syndrome) may occur. Operative treatment is more effective than conservative treatment, which consists primarily of the prevention of exposure to external noxes. According to actual randomised controlled studies the therapy of choice of the primary form in most cases is the simple in situ decompression of the ulnar nerve in the cubital tunnel. This has to be extended at least up to 5-6 cm distally of the medial epicondyle and can be performed in the open or endoscopic technique, both under local anesthesia. Simple decompression is also the therapy of choice in uncomplicated ulnar luxation and in most post-traumatic cases and other secondary forms. In cases of severe bony or tissue changes of the elbow (especially cubitus valgus) the volar transposition of the ulnar nerve may be indicated. This can be performed in a subcutaneous or submuscular technique. Risks of transposition are impairment of perfusion and, above all, kinking caused by insufficient proximal or distal mobilisation of the nerve has to be avoided. In these cases revision surgery is necessary. The epicondylectomy is not common in our country. Recurrences may occur.
Carpal tunnel syndrome and the "double crush" hypothesis: a review and implications for chiropractic.
Associate Professor, Division of Clinical Sciences, Life University, College of Chiropractic, 1269 Barclay Circle, Marietta, Georgia 30060, USA. brussell@life.edu.
ABSTRACT: Upton and McComas claimed that most patients with carpal tunnel syndrome not only have compressive lesions at the wrist, but also show evidence of damage to cervical nerve roots. This "double crush" hypothesis has gained some popularity among chiropractors because it seems to provide a rationale for adjusting the cervical spine in treating carpal tunnel syndrome. Here I examine use of the concept by chiropractors, summarize findings from the literature, and critique several studies aimed at supporting or refuting the hypothesis. Although the hypothesis also has been applied to nerve compressions other than those leading to carpal tunnel syndrome, this discussion mainly examines the original application - "double crush" involving both cervical spinal nerve roots and the carpal tunnel. I consider several categories: experiments to create double crush syndrome in animals, case reports, literature reviews, and alternatives to the original hypothesis. A significant percentage of patients with carpal tunnel syndrome also have neck pain or cervical nerve root compression, but the relationship has not been definitively explained. The original hypothesis remains controversial and is probably not valid, at least for sensory disturbances, in carpal tunnel syndrome. However, even if the original hypothesis is importantly flawed, evaluation of multiple sites still may be valuable. The chiropractic profession should develop theoretical models to relate cervical dysfunction to carpal tunnel syndrome, and might incorporate some alternatives to the original hypothesis. I intend this review as a starting point for practitioners, educators, and students wishing to advance chiropractic concepts in this area.
Double crush syndrome: an analysis of age, gender and body mass index.
Neurology Department, Zahedan University School of Medicine, Khatam Teaching Hospital, Zahedan, Iran. moghtaderi@zdmu.ac.ir
OBJECTIVES: The aim of this study is to evaluate the role of age, gender, body mass index (BMI), wrist ratio and median sensory nerve conduction velocity as independent risk factors for double crush syndrome (DCS) and to analyze the strength of association of these factors. PATIENTS AND METHODS: We have undertaken a case-control study in 142 patients (125 females) with carpal tunnel syndrome (CTS) and 109 controls. Based on clinical and electrophysiologic criteria 106 pure CTS patients and 36 DCS patients as well as 62 female and 47 male control subjects were selected from patients and their relatives referred to our tertiary referral hospital. Totally nerve conduction studies and electromyographic examination were done in 201 hands. Height, weight, BMI, wrist width, depth, circumference and ratio were measured in all patients and control group. Mean values of different risk factors for DCS group and controls were measured. A logistic regression analysis was conducted to evaluate odds ratio of different risk factors. RESULTS: The mean values for age was greater in DCS patients than CTS group. Male gender and increasing age had odds ratio of 4.19 (CI 95%: 1.35-12.96) and 1.13 (CI 95%: 1.07-1.19), respectively. CONCLUSION: Our study confirms that male gender and increased age are independent risk factors for DCS. We suggest that in elderly men presenting with CTS, electrophysiologic screening for cervical radiculopathy should be considered because the treatment of DCS differs from pure CTS.
Double crush syndrome evaluation in the median nerve in clinical, radiological and electrophysiological examination.
Flak M, Durmala J, Czernicki K, Dobosiewicz K.
Department of Medical Rehabilitation, School of Healthcare, Medical University of Silesia, Katowice, Poland.
Double crush syndrome (DCS) was first described by Upton and McComas who proposed that focal compression of an axon often occurs at more than one level. The aim of the study was to support the hypothesis of DCS of the median nerve on the basis of available diagnostic methods. 30 patients (25 F and 5 M aged 33-73, mean 54.6+/-8.2 years) with coexisting carpal tunnel syndrome (CTS) and cervical radiculopathy (CR) were examined. Control group included 40 healthy volunteers (27 F and 13 M aged 17-82, mean 43.1+/-11 years). Medical evaluation comprised clinical examination, X-ray and MR imaging of the cervical spine, electroneurography (ENG) with F-wave and somatosensory evoked potentials (mSEPs) of median nerves. In clinical examination 96.6% of patients suffered from cervical spine pain and nocturnal paresthesies of at least one hand. Muscular atrophy was present in 43.3% in the proximal and in 70% in the distal part of the upper extremity. 30.3% of patients presented with a thoracic scoliosis. On X-ray examination, all patients showed cervical discopathy, mostly C5-C6 (70%) and C6-C7 (53.3%). Using MR investigation, the narrowing of intervertebral foramina was present in 81.25% and narrowing of vertebral canal in 37.5%. On ENG all patients presented with CTS, bilaterally in 73.3%. The F wave was abnormal in 73.3% and mSEPs in 66.7% of patients. Coincidence of MR and mSEPs in view of lateralization was observed in 71.4%. Results supported the DSC hypothesis. DCS evaluation requires both structural and functional diagnosis of peripheral neurones using MRI and electrophysiological examination
이상근 증후군에 관한 논문
Anatomical, clinical and electrical observations in piriformis syndrome.
Jawish RM, Assoum HA, Khamis CF.
Medical School, St Joseph University, Beirut, Lebanon. rjawish@cyberia.net.lb.
ABSTRACT: BACKGROUND: We provided clinical and electrical descriptions of the piriformis syndrome, contributing to better understanding of the pathogenesis and further diagnostic criteria. METHODS: Between 3550 patients complaining of sciatica, we concluded 26 cases of piriformis syndrome, 15 females, 11 males, mean age 35.37 year-old. We operated 9 patients, 2 to 19 years after the onset of symptoms, 5 had piriformis steroids injection. A dorsolumbar MRI were performed in all cases and a pelvic MRI in 7 patients. The electro-diagnostic test was performed in 13 cases, between them the H reflex of the peroneal nerve was tested 7 times. RESULTS: After a followup 1 to 11 years, for the 17 non operated patients, 3 patients responded to conservative treatment. 6 of the operated had an excellent result, 2 residual minor pain and one failed. 3 new anatomical observations were described with atypical compression of the sciatic nerve by the piriformis muscle. CONCLUSION: While the H reflex test of the tibial nerve did not give common satisfaction in the literature for diagnosis, the H reflex of the peroneal nerve should be given more importance, because it demonstrated in our study more specific sign, with six clinical criteria it contributed to improve the method of diagnosis. The cause of this particular syndrome does not only depend on the relation sciatic nerve-piriformis muscle, but the environmental conditions should be considered with the series of the anatomical anomalies to explain the real cause of this pain.
Piriformis syndrome and low back pain: a new classification and review of the literature.
Spinal Surgical Service, Weill Medical College of Cornell, 535 East 70th Street, New York, NY 10021, USA. papadoulose@hss.edu
Piriformis syndrome is a common cause of low back pain. It is often not included in the differential diagnosis of back, buttock, and leg pain. Additionally it has received minimal recognition because it is often seen as a diagnosis of exclusion. Familiarity with the common elements of the syndrome should increase its recognition and facilitate the appropriate treatment. These include buttock pain and tenderness with or without electrodiagnostic or neurologic signs. Pain is exacerbated in prolonged sitting. Specific physical findings are tenderness in the sciatic notch and buttock pain in flexion, adduction, and internal rotation (FADIR) of the hip. Imaging modalities are rarely helpful, but electrophysiologic studies should confirm the diagnosis, if not immediately, then certainly in a patient re-evaluation and as such should be sought persistently. Physical therapy aims at stretching the muscle and reducing the vicious cycle of pain and spasm. It is a mainstay of conservative treatment, usually enhanced by local injections. Surgery should be reserved as a last resort in case of failure of all conservative modalities. Piriformis syndrome may constitute up to 5% of cases of low back, buttock, and leg pain. Recognition and widespread appreciation of the clinical presentation improves its early detection and accurate treatment.
Piriformis syndrome, diagnosis and treatment.
Kirschner JS, Foye PM, Cole JL.
Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey- New Jersey Medical School, Administrative Complex Building 1, 30 Bergen Street, Newark, New Jersey 07101-1709, USA. jkirschnerMD@gmail.com
Comment in:
Piriformis syndrome (PS) is an uncommon cause of sciatica that involves buttock pain referred to the leg. Diagnosis is often difficult, and it is one of exclusion due to few validated and standardized diagnostic tests. Treatment for PS has historically focused on stretching and physical therapy modalities, with refractory patients also receiving anesthetic and corticosteroid injections into the piriformis muscle origin, belly, muscle sheath, or sciatic nerve sheath. Recently, the use of botulinum toxin (BTX) to treat PS has gained popularity. Its use is aimed at relieving sciatic nerve compression and inherent muscle pain from a tight piriformis. BTX is being used increasingly for myofascial pain syndromes, and some studies have demonstrated superior efficacy to corticosteroid injection. The success of BTX in treating PS supports the prevailing pathoanatomic etiology of the condition and suggests a promising future for BTX in the treatment of other myofascial pain syndromes.
The piriformis syndrome.
Parziale JR, Hudgins TH, Fishman LM.
Brown University, School of Medicine, Providence, Rhode Island, USA.
Comment in:
Piriformis syndrome is an often misdiagnosed cause of sciatica, leg, or buttock pain, and disability. The sciatic nerve may be compressed within the buttock by the piriformis muscle, with pain increased by muscular contraction, palpation, or prolonged sitting. A thorough medical history and physical examination are essential to proper diagnosis. Diagnostic testing may be used to differentiate piriformis syndrome from other causes of sciatica, lower extremity weakness, and pain. This article reviews the pathophysiology and management of piriformis syndrome.
Pain in the buttock that radiates down the leg is commonly called sciatica. The most common cause for sciatica is irritation of the spinal nerves in or near the lumbar
spine. Sometimes the nerve irritation is not in the spine but further down the leg. One
possible cause of sciatica is piriformis syndrome. Piriformis syndrome can be
painful, but it is seldom dangerous and rarely leads to the need for surgery. Most people
with this condition can reduce the pain and manage the problem with simple methods, such as physical therapy.
This guide will help you understand
What parts of the body are involved?
The lower lumbar spinal nerves leave the spine and join to form the sciatic nerve. The sciatic nerve leaves the pelvis through an opening called the sciatic notch.
The piriformis muscle begins inside the pelvis. It connects to the sacrum, the triangular shaped bone that sits between the pelvic bones at the base of the spine. The connection of the sacrum to the pelvis bones forms the sacroiliac joint. There is one sacroiliac joint on the left and one on the right of the low back. The other end of the piriformis muscle connects by a tendon to the greater trochanter, the bump of bone on the top side of your hip.
The piriformis muscle is one of the external rotators of the hip and leg. This means that as the muscle works, it helps to turn the foot and leg outward. Problems in the
piriformis muscle can cause problems with the sciatic nerve. This is because the sciatic
nerve runs under (and sometimes through) the piriformis muscle on its way out of the
pelvis. The piriformis muscle can squeeze and irritate the sciatic nerve in this area,
leading to the symptoms of sciatica.
Related Document: A Patient's Guide to Lumbar Spine Anatomy
What causes this problem?
The symptoms of sciatica come from irritation of the sciatic nerve. It's still a mystery
why the piriformis muscle sometimes starts to irritate the sciatic nerve. Many doctors
think that the condition begins when the piriformis muscle goes into spasm and tightens
against the sciatic nerve, squeezing the nerve against the bone of the pelvis.
In some cases, the muscle may be injured due to a fall onto the buttock. Bleeding in and around the piriformis muscle forms a hematoma. A hematoma describes the blood that has pooled in that area. The piriformis muscle begins to swell and put pressure on the sciatic nerve. Soon the hematoma dissolves, but the muscle goes into spasm.
The sciatic nerve stays irritated and continues to be a problem. Eventually the muscle
heals, but some of the muscle fibers inside the piriformis muscle are replaced by scar
tissue. Scar tissue is not nearly as flexible and elastic as normal muscle tissue. The
piriformis muscle can tighten up and put constant pressure against the sciatic nerve.
What does the condition feel like?
Piriformis syndrome commonly causes pain that radiates down the back of the leg. The pain may be felt only on one side, though it is sometimes felt on both sides. The pain can radiate down the leg all the way to the foot and may be confused for a herniated disc in the lumbar spine. Changes in sensation and weakness in the leg or foot are rare. Some
people say they feel a sensation of vague tingling down the leg.
Sitting may be difficult. Usually people with piriformis syndrome do not like to sit.
When they do sit down, they tend to sit with the sore side buttock tilted up rather than
sitting flat in the chair.
How do doctors diagnose the problem?
Diagnosis begins with a complete history and physical exam. Your doctor will ask
questions about your symptoms and how the pain is affecting your daily activities. Your
doctor will also want to know what positions or activities make your symptoms worse or
better. You will be asked about any injuries in the past and about any other medical
problems you might have such as any arthritis that runs in the family.
Next the doctor examines you by checking your posture, how you walk, and where your pain is located. Your doctor checks to see which back movements cause pain or other symptoms.
Your skin sensation, muscle strength, and reflexes are also tested because it is
difficult to distinguish pain coming from the sacroiliac joint from pain coming from
other spine conditions.
If there is any question whether you might have an infection or some type of arthritis
affecting multiple joints, laboratory tests may be ordered. You may need to have blood
drawn and give a urine sample to send to the laboratory for special tests.
X-rays are commonly ordered of both the low back and pelvis. X-rays can give your doctor an idea about how much wear and tear has developed in the sacroiliac joint. X- rays of the lumbar spine and hips are also helpful to rule out problems in these areas that may look and act like sacroiliac joint problems.
Other radiological tests may also be useful. A magnetic resonance imaging (MRI) scan can be used to look at the lumbar spine and pelvis in much more detail and rule out other conditions in the area conditions. The MRI scan uses magnetic waves rather than X-rays and shows a very detailed picture of the soft tissues of the body.
A special type of MRI scan called neurography is being used more frequently to look at nerves. This uses a regular MRI scanner, but the computer settings are set to
look for areas of irritation along a nerve. This may change the way doctors use the
MRI to diagnose nerve problems such as piriformis syndrome, thoracic outlet syndrome, and carpal tunnel syndrome.
A bone scan is useful to see how the skeleton is reacting to any type of "stress," such as an injury, an infection, or inflammation from arthritis. Chemical "tracers" are injected into your blood stream. The tracers then show up on special spine X- rays. The tracers collect in areas where the bone tissue is reacting strongly to some type of stress to the skeleton, such as arthritis and infection of the sacroiliac joint.
The most accurate way to tell if the piriformis muscle is the cause of pain is with a
diagnostic injection into the muscle. The muscle is deep inside the buttock, so the
injection requires X-ray guidance with a fluoroscope, a CT scanner, or an open
MRI machine. Once the needle is placed in the muscle, an anesthetic can be injected
into the muscle to paralyze the piriformis muscle. If the pain goes away after the
injection, your doctor can be reasonably sure that the pain you are feel is from
piriformis syndrome.
What treatment options are available?
Doctors often begin by prescribing nonsurgical treatment for piriformis syndrome. In some cases, doctors simply monitor their patients' condition to see if symptoms improve. Anti-inflammatory medications, such as ibuprofen and naproxen, are commonly used to treat the pain and inflammation caused by the irritation on the nerve. Acetaminophen (for example Tylenol?) can be used to treat the pain but will not control the inflammation.
You'll probably work with a physical therapist. After eval!uating your condition, the therapist uses treatments to ease spasm and pain in the piriformis muscle. Exercises,
particularly stretching exercises, are given to try and relieve irritation on the sciatic nerve.
If you still have pain after trying these treatments, your doctor may suggest injections.The main use of injections is to see if your pain is from piriformis syndrome. An injection of local anesthetic such as lidocaine can be injected into the muscle to temporarily relax it. This loosens up the muscle and reduces the irritation on the sciatic nerve. Other medications have also been injected into the piriformis muscle.
Cortisone, for example, may be mixed with the anesthetic medication to reduce the inflammation on the sciatic nerve. Cortisone is a potent anti-inflammatory medication
that is commonly used both in pill form and in injections to treat inflammation.
Related Document: A Patient's Guide to Piriformis Muscle Injections
Botulism injection therapy (also known as Botox? injections) can be used to actually paralyze the piriformis muscle. This makes the muscle relax, which helps take pressure off the sciatic nerve. The effect of the Botox? injection isn't permanent; it generally only lasts a few months. In the meantime, however, it is hoped that a stretching program can be used to fix the problem. In other words, when the injection wears off, the muscle may have been stretched enough so that the symptoms do not return.
Surgery may be considered but usually only as a last resort. There are two procedures in use. The first is to cut the piriformis tendon where it attaches on the greater
trochanter (the bump on the side of your hip). The other method is to cut through the
piriformis muscle to take pressure off the sciatic nerve.
These procedures are usually done on an outpatient basis, meaning that you will be able to go home the same day as the surgery. In some cases, you may need to stay in the
hospital for one night. Both procedures can be done under general anesthesia or under a
spinal type of anesthetic.
The surgeon begins by making a small incision, usually about three inches long, in the buttock. The fibers of the gluteus maximus, the largest buttock muscle, are split. This
gives the surgeon a way to see deep into the buttock and locate the piriformis muscle.
When the piriformis muscle and tendon can be seen, the surgeon then cuts (releases)
the tendon where it connects to the greater trochanter.
If more room is needed to release the pressure on the nerve, a portion of the piriformis muscle may be removed. This usually doesn't cause problems with strength because there are several much stronger muscles that help turn the leg outward.
What should I expect as I recover?
Most patients with piriformis syndrome work with a physical therapist. Plan to attend
physical therapy sessions two to three times each week for six to eight weeks.
Your therapist begins by eval!uating your condition. This includes attention to the low
back, as well as the sacroiliac and hip joints.
Physical therapy treatments for piriformis syndrome often begin with heat applications. Heat is used to help the piriformis muscle relax, easing spasm and pain. Your physical therapist may place a hot pack over your buttocks muscle.
Ultrasound is another treatment choice that can be set for deep heating in the buttock
area. Ultrasound uses high frequency sound waves that are directed through the skin. The
deep heating effect of ultrasound is ideal for preparing the piriformis muscle for hands-
on forms of treatment and for getting the muscle to stretch out.
Hands-on treatments such as deep massage and specialized forms of soft-tissue
mobilization may be used initially. Your therapist may also position your hip and leg in
a way that helps to relax nerve signals to the piriformis.
The keystone treatment for piriformis treatment is stretching. Stretching is especially
effective following heat and hands on treatments. Your therapist will position you in
ways that help you get a good stretch on the piriformis muscle. Along with the stretches
you'll do in the clinic, you'll be shown several ways to stretch the muscle on your own.
You need to do your stretches every few hours. Be gentle and cautious as you stretch to
avoid overdoing it.
As your symptoms ease, your therapist will gradually advance your program to include posture training, muscle strengthening, and general conditioning.
Your surgeon may prescribe physical therapy after surgery for piriformis syndrome. You'll probably only need to attend sessions for four to six weeks. Expect full recovery to take up to three months.
During therapy after surgery, your therapist may use treatments such as heat or ice,
electrical stimulation, massage, and ultrasound to help calm pain and muscle spasm. Then
you'll begin learning how to move safely with the least strain on the healing area.
As the rehabilitation program evolves, you'll begin doing more challenging exercises. The goal is to safely advance strength and function.
As the therapy sessions come to an end, your therapist helps you get back to the
activities you enjoy. Ideally, you'll be able to resume normal activities. You may need
guidance on which activities are safe or how to change the way they go about their
activities.
When treatment is well under way, regular visits to your therapist's office will end.
Your therapist will continue to be a resource. But you'll be in charge of doing your
exercises as part of an ongoing home program.
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