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The clinical features of the piriformis syndrome: a systematic review

Abstract

Piriformis syndrome, sciatica caused by compression of the sciatic nerve by the piriformis muscle, has been described for over 70 years; yet, it remains controversial. The literature consists mainly of case series and narrative reviews. The objectives of the study were: first, to make the best use of existing evidence to estimate the frequencies of clinical features in patients reported to have PS; second, to identify future research questions. A systematic review was conducted of any study type that reported extractable data relevant to diagnosis. The search included all studies up to 1 March 2008 in four databases: AMED, CINAHL, Embase and Medline. Screening, data extraction and analysis were all performed independently by two reviewers. A total of 55 studies were included: 51 individual and 3 aggregated data studies, and 1 combined study. The most common features found were: buttock pain, external tenderness over the greater sciatic notch, aggravation of the pain through sitting and augmentation of the pain with manoeuvres that increase piriformis muscle tension. Future research could start with comparing the frequencies of these features in sciatica patients with and without disc herniation or spinal stenosis.

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Acknowledgments

We thank Mrs Wendy Marsh, Head of Knowledge Services, Ipswich PCT for assistance with retrieval, and Prof. Milos Jenicek and Prof. Paul Glasziou for comments on the assessment of case studies. The study was partly funded by a grant from the Scientific Foundation Board of the Royal College of General Practitioners. The authors are independent of the funding body.

Conflicts of interest statement

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Correspondence to Kevork Hopayian.

Appendices

Appendix 1: Anatomy of the PM

The PM originates from the pelvic surface of the sacral segments S2–S4, the sacro-iliac joint, the anterior sacro-spinous ligament and the sacro-tuberous ligament. It passes through the greater sciatic notch to insert onto the greater trochanter of the femur. The sciatic nerve exits the pelvis below the belly of the muscle. Many congenital variations exist: the nerve may divide proximally, the nerve or a division of the nerve may pass through the belly of the muscle through its tendons or between the part of a congenitally bifid muscle [85, 86]. The PM externally rotates, abducts and partially extends into the hip.

Appendix 2: Data extraction form for individual patient data

Citation

Type of study

Patient identification number

  • Symptoms

    • Buttock pain

    • Low back pain

    • Difficulty in sitting or pain aggravated by sitting

    • Dyspareunia

  • Signs specific for PS

    • External tenderness over the greater sciatic notch

    • Internal tenderness of the PM on vaginal or rectal examination

    • Freiberg test

    • Pace test

    • Beatty test

    • Tonic external rotation of the hip

    • Flexion–adduction–internal rotation (FAIR) painful

  • Routine sciatica signs

    • Limited SLR or positive Lasegue

    • Knee or ankle tendon reflex diminished

    • Sensation along dermatomes L4, L5 and S1 diminished

    • Power in myotomes L3/L4 and L5/S1 diminished

Appendix 3: Items in the quality assessment in case studies of PS

Description

  1. 1.

    Were all relevant demographic features, namely, age and sex, described?

  2. 2.

    Were key features in the history reported? These are onset whether acute or gradual, site of pain, radiation, relieving and aggravating factors, duration, evolution of the condition and past medical history.

  3. 3.

    Were routine sciatica examinations reported: sensation, power, tendon reflexes, straight leg raising/Lasegue?

  4. 4.

    Was at least one examination specific for PS reported: external rotation of foot, Freiberg sign, Pace sign, Beatty sign, Flexion–Adduction–Internal Rotation (FAIR) test?

Case definition

  1. 5.

    Was there corroborating evidence?

Selection

  1. 6.

    Applies only for case series

Was the method of selection free of bias, for example, through recruitment of consecutive cases?

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Hopayian, K., Song, F., Riera, R. et al. The clinical features of the piriformis syndrome: a systematic review. Eur Spine J 19, 2095–2109 (2010). https://doi.org/10.1007/s00586-010-1504-9

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  • DOI: https://doi.org/10.1007/s00586-010-1504-9

Keywords

  • Piriformis
  • Sciatica
  • Diagnosis
  • Systematic review