In this case study, we explore the oft-considered “Piriformis syndrome” diagnosis and show how similar pain can be related to many different issues – each diagnosed accurately with MR Neurography.
Many believe they have Piriformis Syndrome, but it’s not well known that Piriformis Syndrome covers a broad range of orthopedic and soft tissue injuries, including vascular and peripheral nerve elements.
There are as many Piriformis combinations as there are patients, and no two Piriformis patients are exactly alike. Some patients report pain only during activity like while sitting; they experience pins and needles sensations from the hip down the leg. Other patients report constant dull, throbbing pain that radiates around the thigh with numbness in the balls of the feet. Given the variety of patient factors, confirming the diagnosis can sometimes be difficult.
Ever since the groundbreaking medical publication in the February 2005 Journal of Neurosurgery: Spine (click here), there are more and more Piriformis providers who are treating this condition. However, many of these providers lack the one essential tool required to successfully diagnose and treat this condition.
This month’s case features a patient who had been diagnosed with Piriformis Syndrome and was considering surgery as her next step. After almost five years of treatment ranging from CT injection to radio frequency ablation with little change in symptoms, this 50-year-old woman was still suffering from pelvic pain on both sides.
Working on a hunch that the diagnosis may be incomplete, her local chiropractor referred her for suspected Piriformis Syndrome and requested a MR Neurography scan and study from The Neurography Institute, conducted at our St. Petersburg, Florida, location. Ironically, the patient thought that the Neurography test might turn out to be a waste of time and money, since over the years she had completed a number of diagnostic tests including a 3T MRI in New York and a soft-tissue pelvis MRI in Baltimore, Maryland. Using these diagnostic tools, the doctors were only interested in the very large Tarlov cysts on her RIGHT side.
Upon receiving the referral, The Neurography Institute conferred with her treating doctor to create an individualized Neurography protocol with attention to both sides of the pelvis, lower lumbar, and special attention to the left side. The MR Neurography scan showed on the right side a large complex Tarlov cyst, which extended from the right S2 spinal root a linear distance of nearly 7.0 cm, which is extraordinarily large and the cyst was approximately 2.0 cm in diameter. On the left side, the MR Neuorgaphy showed a much smaller Tarlov cyst approximately 4.0 mm in diameter. The Piriformis muscles were asymmetric and quite thin on the left side, in comparison with the right. The obturator internus muscles were asymmetric, and surprisingly there was a significant pathology affecting the left Obturator Internus muscle.
The 3D reconstruction and image post-processing that is key for MR Neurography scans provided by The Neurography Institute showed that the left obturator internus muscle had significant hemorrhage, which would be consistent with a rupture of the obturator internus muscle on the left side. This appeared to result from recent injections into the obturator internus muscle, as the muscle appeared to be normal in structure with discoloration consistent with resolving blood. The fading extended along the Pudendal nerve elements in the Alcock’s canal area and reached the Ischial spine. The sciatic nerve itself did not show any significant injury or change; although there were fascicle components of the nerve that showed some moderate irritation as they descended to the level of the Obturator Internus tendon.
Based on the MR Neurography result findings, the local treating doctor was able to modify and develop a treatment plan without the need for Piriformis surgery.
While many people seek out other patients to compare treatment plans and notes on providers, this case illustrates the real complexity of the Piriformis patient: A Confirmed Diagnosis. Patients vary, symptoms vary, treatments vary and even providers can vary.
Consequently, it is all the more important for patients to complete a genuine MR Neurography before undergoing Pirformis surgery. Having a high density and detailed imaging study provides peace of mind, so if you think that you have Piriformis Syndrome, contact the Neurography Institute.
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