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Treatment of Piriformis Muscle Syndrome with Botulinum Toxin-A

Treatment of Piriformis Muscle Syndrome with Botulinum Toxin-A

Anesthesiology Abstracts of Scientific Papers Annual Meeting ( ): Abstract No A-879

Piriformis syndrome has been documented as a primary or contributory cause of "sciatica" and low back pain. We present a retrospective review of fifety patients who underwent intrapiriformis muscle botox injection with remarkable pain relief at 6 to 8 weeks follow-up.The demographic characteristics of the study group is given in Table I. Our diagnostic criteria for piriformis muscle syndrome are: Gluteal pain with or without pain radiating down the affected leg in the distribution of sciatic nerve, muscle spasms/pull in leg muscles, positive Beatty's Maneuver with or without the presence of tenderness in buttock, and L5 or S1 sensory nerve root hypoesthesia of A-delta fibers on affected side. V-sNCT, Voltage-Sensitive Nerve Conduction Threshold, is a direct quantitative sensory test (QST), which provides a reproducible (<0.2mA) functional assessment of the peripheral sensory nervous system by measuring that voltage intensity which initiates membrane potential changes, to propagate a nerve impulse. The Botulinum-toxin A used for injection is a standardized preparation. 100 Units of BotoxTM in 5 cc of preservative-free 0.9 N saline was injected into the piriformis muscle,under fluroscopic guidance. Results: All patients reported a reduction in pain score. VAS pain score in the study population (n=50) was 8.87+- 0.15 prior to treatment and 4.5+-0.2 after treatment (p<0.01). McGill score (n=27) was 40.6 +-3.04 before and 21.5 +-2.51 after the injection (p<0.01), Oswestry (n=27) changed from 25.9+- 1.26 to 11.7 +- 1.02(p<0.01) and Roland-Morris (n=27) decreased from 16.0 +- .935 to 20.6+- 1.02 (p<0.01). Discussion Botulinum toxin-A** is a 150 Kda protein neurotoxin,produced by Clostridium botulinum, which acts presynaptically by inhibiting the release of acetylcholine, thus leading to functional denervation of the muscle . This lasts up to 6 months. The piriformis muscle is a pyramidal muscle, which arises from the ventrolateral aspect of the sacrum from S1-S4, gluteal surface of ilium and the anterior capsule of the sacroiliac joint and passes laterally through the greater sciatic foramen to its insertion on greater trochanter of femur. The signs and symptoms of sciatica caused by piriformis syndrome can be explained by the close relationship of the muscle to sciatic nerve at the sciatic notch. A variety of therapeutic approaches have been suggested for the management of piriformis syndrome like analgesics, application of heat, osteopathic manipulation,and even surgical resection of piriformis muscle. Except for the latter, none of these modalities offer significant pain relief, and surgery is associated with morbidity. Ours is the first review where the effect of intrapiriformis muscle botox has been studied. All of our patients who underwent Botox TM injection to piriformis muscle reported a reduction in pain by 45% or more as well as improvement in their disability scores. Therefore we propose that BotoxTM injection to piriformis muscle is an effective treatment for low back pain and sciatica caused by piriformis syndrome.

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