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Kim et al. Common diseases mimicking lumbar disc herniation

Figure 3: The trigger point (*) for gluteus Among patients with LBP, 5-17% manifest piriformis
medius muscle pain is located at the edge of syndrome. [17,19,21-23] Some patients develop piriformis
the gluteus maximus muscle at the midpoint
between the iliac crest (arrow head) and syndrome after percutaneous endoscopic lumbar
greater trochanter (arrow) discectomy (PELD). Kim and Kim [22] reported that
the incidence of piriformis syndrome was 13.7%.
Within 3 months of PELD, 40.4% of operated patients
presented with piriformis syndrome; its incidence
was highest in the first postoperative month. Their
observations suggest that heightened anxiety in
patients undergoing PELD under local anesthesia may
increase the incidence of piriformis syndrome elicited
by walking. They suggested that general anesthesia
may reduce the incidence of piriformis syndrome
practice, we consider GMeM involvement in buttock after PELD, although local anesthesia is preferable
pain when it is located around this muscle. The trigger because it allows for intraoperative monitoring.
point is located on the GMeM at the edge of the gluteus Anxiolytic administration makes intraoperative patient
maximus muscle equidistant from the iliac crest and cooperation difficult, particularly in older patients,
greater trochanter [Figure 3]. Some patients report pain and their use may have adverse effects. A proper
radiation to the lateral-posterior thigh. When transient preoperative period stretching of the piriformis muscle
pain amelioration is obtained by local GMeM block, we may be useful in locally anesthetized patients.
diagnose GMeM pain.
Diagnosis and treatment
When GMeM pain cannot be controlled by medication Piriformis syndrome cannot be identified by radiological
and physiotherapy, GMeM block may be useful. Some and electrophysiological studies; its diagnosis is
patients experience gait disturbance due to transient based on clinical symptoms and palpation. [18-22]
leg paralysis after blockage. Non-responders to During palpation, the swollen, stiff piriformis muscle
conservative therapy may require less invasive GMeM is identified as a sausage-shaped mass over the
decompression surgery under local anesthesia. [6,12] piriformis muscle. There is tenderness, and some
This treatment can benefit even very old patients with patients report radiating pain along the sciatic nerve.
intractable buttock and leg pain due to the GMeM. Symptom alleviation obtained by piriformis muscle
Peripheral block and less invasive surgery under local block is diagnostic. [18,20-22]
anesthesia are other treatment options. [6]
Piriformis muscle stretching is useful in addition to
Piriformis syndrome medication and rehabilitation [Figure 4]. Some patients
Definition and symptoms experience pain alleviation upon piriformis muscle
The piriformis muscle connects the sacrum and greater stretching, but this exercise must be continued for
trochanter. When it is overburdened, buttock pain also more than 2 weeks. When these methods fail, piriformis
involving the adjacent sciatic nerve with nerve pain muscle block may be useful. Piriformis muscle block
down to the lower thigh may be experienced. The pain may elicit transient leg paralysis 30-60 min after injection
is similar to that elicited by S1 radiculopathy and may when the anesthetic reaches the sciatic nerve. Non-
be attributable to anatomic anomalies of the piriformis responders may require piriformis muscle dissection.
and sciatic nerve. It is more common in women than
men. [17,18] Sacroiliac joint pain
Definition and symptoms
There are no specific symptoms. Patients report The sacroiliac joint (SIJ) connects the spine and pelvis;
lower buttock pain and S1-like sciatic pain that rarely it is comprised of articular and posterior ligamentous
involves the ankle. The symptoms are exacerbated by compartments. It is reinforced with hard ligaments and
prolonged sitting, stairclimbing, and walking. [19,20] Some moves only slightly. SIJ pain can be elicited by everyday
patients experience decreased pain with walking. The activities and involves both articular and posterior
etiology of piriformis syndrome involves exercise load, ligament regions. It is felt not only in the lower back and
trauma, and tumor; lumbar spine disease may be an buttocks but also in the groin and lower extremities, it
idiopathic cause. can be difficult to discern from pain secondary to other
disorders. The major pathological factor in SIJ pain
The accurate diagnosis of piriformis syndrome avoids is joint dysfunction. [24] Repetitive movements and/or
FBSS and insufficient decompression after surgery. accidental minor subluxation of the SIJ may damage
Mini-invasive Surgery ¦ Volume 1 ¦ June 30, 2017 45