# Piriformis syndrome: Deep Gluteal Syndrome? Pelvic Outlet Syndrome? by Dr Thierry Monfils

**Channel:** dxbone center
**Source:** https://www.youtube.com/watch?v=5pUccMRsSxo
**Transcript page:** https://www.withtranscript.ai/video/5pUccMRsSxo

## Chapters

- 0:09 — Introduction and Topic Overview
- 2:07 — Piriformis Syndrome and Anatomy
- 7:56 — Causes of Nerve Entrapment
- 11:37 — Clinical Assessment of Piriformis Syndrome
- 20:12 — Differential Diagnosis and Exam Clues
- 27:42 — Imaging and Electrodiagnostic Workup
- 38:36 — Audience Questions on Diagnosis
- 46:59 — Treatment Strategy and Surgical Options
- 56:48 — Closing Remarks and Next Session

## Transcript

**[0:09]:** I see becomes stop so

**[0:16]:** hello everybody yes hello everyone the this is the variable to welcome to ask you again to our seventh I think seventh live broadcast DX bond for arms so you know probably that this is a platform for education that we have developed a few weeks ago with the copied we'd say pregnant lockdown and for that reason we decided to provide some education to our Craig surgeon dr. Chiu sharpest nurse and to discuss about different topic in American spot medicine this live broadcast will be available at any time in our export channels we can register if you want subscribe and you will be able to see that in the future if you don't have time because now people start to go back to the normal normal work and I'm very happy to host to welcome back our correct element is for the this topic today which is the piriformis syndrome it's probably sunroom that a few of you are knowing very well with experience theory as large experience on this topic not only this one and I'm happy that you will provide us your experience and

**[1:50]:** expertise about this some Dom it's all the differential diagnosis so chilly if you want to share your screen the microphone yours

**[2:07]:** thank you very much for this kind introduction my presentation is about the piriformis syndrome more widely piriformis syndrome has to be considered as part of the deep gluteal syndrome and could also be considered as the equivalent in the pelvis to the thoracic outlet syndrome that's what I will try will be to show you in this topic

**[2:40]:** the first description that has been made in 1928 but the name has been given in 1947 by Robinson and since then many of the cause has been discovered because long for a long time the only considerate cause was the piriformis muscles so the other course has been grouped under the name deep gluteal syndrome even if the other name do exist in literature like pelvic outlet syndrome or infra performace foramen just remind during this topic that when we speak about the piriformis syndrome we always speak about pain in the buttock and radically pain so this preforms syndrome has been controversial and confusing quite since the beginning more than 27% of the physical medicine rehabilitation specialists in the United States do not believe that PS exists this PS is confusing so motors sainte-anne it's over diagnosis others that it's under-diagnosed and probably because there is true very big difficulties in these peers first there is multiple responsible

**[4:02]:** factors of static nerve entrapment in the buttock and second the differential diagnosis of buttock pain sciatica and sciatica light pain is very very large so this confusion leads to multiple investigations multiple consultation related to this misdiagnosed pathology so same for the incidents from 0.3% to 17% of sciatica including the radiculopathy 0.7 to 1.6 percent of all the low back pain so this is a very variable incidence according to the definition and the selection methods and even if you consider that this P as is as common as disco genic sciatica so what is really clear is that true incident is not clear at all so for the anatomy just can reminder of the limits of this deep retail space limited posteriorly by this gluteus maximus muscles entirely by the of a margin in the proximal failure medially by this sacrotuberous ligament streusel bit here the Linea aspera laterally super-yummy here the inferior margin of

**[5:28]:** the greater sciatic notch and inferiorly the distal aesthetic border and hamstring region what's the content of this space its muscles its ligaments and it's nerves for the muscles for sure there is the piriformis muscles here but there is also the other external rotator muscles below Gemini's obturator internus and cartridge memories for the ligaments to more important are the sacrotuberous here and sacra spinous ligaments for the nerves more than the static nerve you see here there is also nerves in the space the superior gluteal the inferior gluteal the posterior femoral cutaneous the pudendal and branches for the other external rotator muscles for sure there is the preform is muscles that is centrally positioned in this buttock this muscles inserted on the entire sacrum going through this greatest attic not to insert on the greater trochanter this p.m. is an external rotator when the hip is extended but is also and it's important an objective when the hip is flexed for the patient the aesthetic nervous trudeau piriformis muscle sorry is stretch when the patient is sitting and

**[6:55]:** mostly one is sitting with the legs crossed for the static nerve there is some characteristic that you should know for this topic first the fibers of the common peroneal branch and posterior tibial branch of the Shattuck North are still separated in the proximal shattuck nerve this explaining the distribution of the symptom in the clinical neurological examination in the extremity in case of shattuck nerve entrapment the Shattuck novice Ontario to the piriformis but posterior to the other external rotator explaining a possible seesaw effect between the p.m. and ian's external rotator and finally the static nerve is able to accommodate with motion because he can move by stretching and gliding so now what are the possible cause of static nerve entrapment in this deep little space the

**[7:56]:** most frequent is obviously the piriformis syndrome why because some suspected anatomical variation of the relationship between the p.m. and the static nerve to pinnacles there is many possible variation described first by beaten and 1938 knowing that the type 1 here over which is the normal position of the shattuck nerve and the type 2 when the common peroneal nerve is going through the piriformis muscles are the two more frequent together they represent modern 95-plus but is those are those variation possible cause it's absolutely not true because the prevalence of dose of normal variation is quite the same asymptomatic patient when you do graduate studies and in symptomatic P as patient what is clear is that overuse of the PM is caused by our petrol I petrified by spasm of the PM compressing the sciatic nerve because of vital low doses but because of Cox ephemeral auntie or with reversion because of some activities long activities like running there is also and I told you before the seesaw effect between p.m.

**[9:21]:** and also external rotator the long sitting position for sure especially crossed legs position with this hip flexion and addiction position and if you add to this sitting position the internal rotation position of the hip you have the fair position flexion abduction internal rotation stretching the piano narrowing the space between the p.m. and the sacrotuberous ligament so possibly compressing and compressing the sciatic nerve you can also have a direct or an indirect p.m. damaged by contusion or by excessive stretching sudden stretching during some activities now I told you there is PS but there is also other cause of compression on static nerve in this deep repair space what are those calls possible fibrous bands with the possible image neuropathy of the sciatic nerve gluteal muscle atrophy with a lack of russia' protection of this muscle on the shattuck nerve you can have a proximal hamstring muscle injury accidental or by overuse which

**[10:35]:** tandino potty I told you about this Germany so I complex seesaw effect with the BM you can have also a cause indicial tuberosity with fracture male even the so-called Asia internal syndrome which narrowing of the space between the ischial tuberosity downstream and this family's a little bit the same dish ephemeral impingement impingement narrowing the space between IT and the famous paste and also pasture abnormalities also caused the space-occupying lesion in the BG as for example tumor able to compress the sciatic nerve or a specific cause like launched surgery in seated position like a stable reconstruction like total hip arthroplasty like of the femoral hyper laxity interrogation fracture trauma and others so we saw the PID

**[11:37]:** etiology the possible causes of the BLS we saw the possible cause of the other deep little syndrome now what are the possible cause of sciatica sciatica like pain and buttock pain out of these digits this dip little space if you have a sciatic area sciatica like pain you have to consider possible ready to the body l5 s1 because of discoloration because also of a possible ton of cyst you can see here on the MRI or because of lumber canal stenosis here on this page this coda equina syndrome you can have Auto neuropathies approximately and are brutal posterior femoral cutaneous neuropathy or distally the branch of the static not the tibial and the proneural branch and you can have faith sciatica dr. sudo sciatica related to face joint derangement never forget the multiple sclerosis that can mimic at the beginning of this disease sciatica so also called non dgs causes but of deep retail pain buttock pain consider possible intra pivec a

**[13:04]:** perfect relation consider a possible fracture of the pelvis sacroiliac joint disturbance clue neural nerve impingement also this now coming from the upper lumber spine and giving another innervation of the buttock hip derangement trochanteric bursitis sacrococcygeal derangement so now we saw there is a lot of possible causes of pelvic preform a syndrome of deep little syndrome or other causes coming coming from out of this space what can we have a DES clinic assessment helping us to go out of this differential diagnosis so what are the characteristic of the T has a clinical assessment what are the difference when you have an author DGS cause what are the difference when you have course out of this deep little space causes of buttock pain or causes of sciatica sciatica like for the SPS specific clinical assessment at eastery taking you can frequently have a trauma with a p.m.

**[14:22]:** damage you should have deep literal pain with burning sensation with radiation to the posterior thigh posture calve but never forget that India's the buttock pain should dominate the low back pain this pain is increased characteristically at long sitting at long driving could be also related to overuse the long running long cycling long rowing and modern the buttock pain therapy as should include sciatica like pain for this sciatica leg pain it's mostly numbness and paresthesia on the extremity rarely you will have motor sensory deficit why because of the pathophysiology of the shattuck nerve impingement this is related to transient dynamic repetitive compression of shattuck nerve so it's more three demyelination that you will see the static you have modern real axonal lesion of this now at observation of your a patient entering in your clinic you can see this situation waster right hip external rotation because of in this involve buttock doc reforms muscle spasm and

**[15:48]:** this preforms muscles button you will see it also when the patient is laying on the table with this tonic external rotation you can see leg length discrepancy you can see hyper low doses that are possible causative factor you can see a sacral rotation toward the opposite side because of this piriformis spasm and you can see this sitting positional between the patient avoiding to put pressure on this painful spasm of the preference muscles when you check the range of motion you can have a limitation of internal rotation of the hip and more specifically you will have this restriction of flexion addiction internal rotation the fair position described by Soleil at per patient you frequently will palpate this spasmodic muscle painful muscle and the static not difficult in case of obesity for the neurologic examination I never used the laceration test because of the poor specificity of this test for the differential diagnosis at least and I

**[17:07]:** told you there is rarely motor sensory reflex testing deficit because of the pathophysiology of the sciatic nerve impingement if you have some deficit in the muscle it will be in the distal muscle with an non specific distribution so not specific radicular distribution l5 s1 and not a pure specific this lucien of common peroneal or tibial neuropathy so was this clinical salesmen many time diagnostic will be confusing it remains an exclusion diagnosis this pas so along the story of this p as many or just described many specific tests using stretching of the piano or contraction of this piriformis muscles for the most useful stretching test there is a freiburg test here described patient supine with maximal internal rotation addiction there is the fattest idea i talked about previously fraction addition internal rotation patient supine or patient prone addiction internal rotation passively the palm test the TG c l test described by mitchell using this concept developed

**[18:36]:** by adult that the PM is stretch in external rotation when the hip is flexed more than ninety degrees for the active contraction test of the b and now the most useful are the pace test here with the patient seated flex knee flexed more than 90 degrees and exerting a manually resisted hip abduction the be distressed patient sidelines with hip and knee flexed and with a manually resisted abduction external rotation contracting the preforms muscles now the furthest but the active firt has developed by fishman patient sideline in fair position and asking this patient to do a fraction external rotation and abduction so for myself I use the Association described by Michele using the Fryeburg the passive face or in test digital and the bitties test with good sensitivity good specificity if I want have more specificity are you so the active fisherman furthers the pace on the pan test and I told you I never use

**[19:53]:** the laissez test another tool that Mitchell gave us is this diagnostic criteria list you can see on the right side of the slide with 12 Creek area if you have eight criteria positive from 12 the diagnosis of peers

**[20:12]:** is quite sure with a good sensitivity and good specificity so now that we saw the clinical assessment of the specific piriformis syndrome what are the difference where's the other DG as schools of Shattuck northern from logical admissions criteria should be less than 8 but never forgotten be careful many of the 12 criteria are compatible with every causes of shattuck nerve increment what are the positive symptoms at easter retaking if you have a sudden onset of pain if your area after sudden movement think about unstring injury if history there is accident for route traffic accident suspect a fraction not omar something else if the pain is mostly at ischial tuberosity think about am stirring tendon nobody now is if the pain is more mechanical than postural like in the BS you can think about fracture aversion and tendon nobody if story taking you have this red flag we send abnormal with loosening without explanation you have

**[21:31]:** to consider a possible new class and never forget a possible previous pelvic or hip surgery previous intra little injection that possible cause of certain nerves in trouble now at clinical examination of these ossicles of shattuck nerve entrapment in the deep retail space you shouldn't have this tonic external rotation even you can have the patient coming walking internal rotation in case of femoral anteversion so if you have been at the ischial tuberosity think about the hamstring injury and do the resisted testing and stretch testing the Pronin orava test the bent knee stretch test and eventually the taking of the show text you can use other specific tests patek bond package in searching for fracture searching for stress fracture palpate for an eventual tumor in the buttock check an eventual cox often hyper laxity and if you suspect an issue of impingement do this issue femoral impingement test with specific stanchion addiction external rotation or do the

**[22:46]:** long strike walking test asking your passion to work with very large step now if we consider the non digits causes of little pain so buttock pain but originated out of the deep little space in that case the mission scooter will be negative less than eight even less than six at least we taking you can have gene ecological clues you can have pain in the sacroiliac inflammatory light in the ankylosing spondylitis or more mechanical you if you have a true mass respected pelvic fracture or sacrococcygeal dislocation if you also have been at the groin if you have morning stiffness less than 60 minutes if the pain is more mechanical and postural consider and a virtual hip derangement if you have lateral or posture pain consider versatile bursitis of the tracking through country or Kousaka Danya now in clinical examination of those non Digia schools of gluteal pain you have to palpate the pelvis the trochanter in

**[24:04]:** the Coxes and you can use specific tests like again this bolt location test for fracture and for sacroiliac joint the specific test thus I trust test the Gans llantas decipher iliac compression and distraction test under sacral test if now you suspect hip derangement the purpose if that could be positive but more on a mechanical mode and among postural mode like in the PS and you can also use the fiber test and you have to check an eventual mechanical restricted range of motion especially in internal rotation now for the non dgs sciatica or sciatica light pain also the missile treaty will be negative less than it less than six at easter retaking in that case the low back pain should dominate WP if you have pain at the upper lumbar spine think at this clear neuropathy if you are perineal sensory Ranieri fainter sexual these turbines consider pudendal neuropathy and the cauda equina syndrome if you

**[25:27]:** have sensory disturbance a posterior thigh consider posterior femoral cutaneous nerve party now if the patient complains of C attica light pain but not below the knee and without numbness you have absolutely to evoke a possible facet syndrome if the patient complains of pain at walking but decreasing rapidly and sitting it's an indication of cauda equina syndrome and if the valsalva test is positive if the discussion excited now a clinical examination of those non digits cause of Seattle Seattle calliope I told you if you have a drug food probably it's not a PS preform single it's more likely a common peroneal neuropathy or 5 radical body if at palpation there is pain at the posterior iliac it could be a cleaner annual party now you have to do a very cautious with neurologic examination of the extremity and if you have a specific distribution of the radical and v or s1 neuropathy a radical party if

**[26:43]:** you have something that is specific of a common panel or posterior tibial distribution think about those causes if you have meters and my name is gluteal weakness it could be a super great beauty of your body now if at this cautious neurologic examination you have something a little bit confusing mixing preference and 2015 deficit mixings symptoms of sciatica nerve and also knows you have to evoke multiple sclerosis you can finally use two specific tests one for the security adjoint a seated extension rotation test and one for the discussion abyss ionica the swamp test now this clinical examination can give you a bundle of clues about the PS about the dgs about non dgs causes of

**[27:42]:** buttock pain of sciatica and sciatica like but many times the diagnosis will remain confusing after clinical examination so it's imaging and complementary investigation able to give you information to go out of this confusion and this differential diagnosis the most useful test you can use is the ultra saw this person can give you information about PM performs muscle and static nerve enlargement if and even if there is no consensus about this this enlargement could be bilateral is difficult to assess in case of obesity but has the advantage to show dynamic change in the piriformis and static nerve relationship the this resin can also show you gluteus maximus r-25 and nowadays we use the high-resolution ultrasound that is more reliable I will talk a little bit later about ultrasound quite diagnostic injection less available but more accurate is the MRI that can show us congestion around the static nerve or change in the relation between p.m.

**[28:59]:** and essen and now we use specific sequences the MRI nuraghe Rafi that can show a static north anatomic details and abnormalities like in this picture here where you see the left shot Iike that doesn't have the same aspect than the right Satya so this is a situation of many sequence of Amara Amara have a good specificity and sensitivity confirmed by surgical decompression result now this rod gives you a picture a picture of the relationship between p.m. and SN and eventual modification of the structure of the SM but is this picture related to the function and the dysfunction of static lock that you observed at the clinical examination the MRI will not give you this information so is energy able to give this affirmation after relation EMG with which is the recording of the muscle electrical activity with an electrode and able to show me denervation sign in case of the Novation is really positive and

**[30:13]:** always for the same pathophysiological reason of the same entrapment but if you have innovation it will be more commonly in the common renewal than in the posterior tibial fibers and you will not have the Novation never in the Prophet Ibrahim returning innovation which are innovated by branches emerging before the piriformis muscles now I told you the pathophysiology of the static nerve gives more demyelination of the shed so is is it possible to assess this conviction slowing of the static vocally with nerve conduction studies the only useful test is the H reflex you can see here is a tree flanked by stimulation of the sensory fibers of the static nerve here at the knee eliciting dist reflex loop crossing the spinal cord and giving this contraction here in the sural muscle recorded with surface electrode so unfortunately this 83 flag is not useful in the normal resting position so fishman developed the fair test each reflex

**[31:35]:** so the same a tree flag but in the fair position increasing the compression of the shattuck nathangood preforms muscle so increasing the reduction of the velocity in the shattuck nerve and delaying the edge reflex so he showed that difference of modern 1.86 milligan comparing the rest it reflects to the fair age reflex is indicative of PS with a good sensibility and specificity this has been confirmed by some motors a little bit one less by other authors but my master in an mg dr. photo Missoula did a study that confirm that the difference right left of more than 0.5 milliseconds at the fair test is indicative of a performance syndrome in conclusion for the investigation of the PS I will recommend ultrasone an en mg as first step investigation for the PS a Merrin an en mg for follow-up over the time of the PS knowing that ultrasound Ameren and energy requires absolutely high technical expertise to be accurate now what about the

**[32:56]:** imaging and complementary investigation for the author d GS of shattuck nerve entrapment III can show you fractured leg length discrepancy I produces increased sacral slope it was sound can show you which is up for financing injury and use ultrasound guided diagnostic injection will be helpful for some diagnosis like this issue of femoral impingement syndrome or for the gemenese oh I see some effect on MRI will be on full in case of fracture or showing you the issue from a gap narrowing showing new customization and these abnormal vascular issues if you suspect now non DGS cause of see attica if you suspect a radical party you will order a spine MRI searching for different causes of the l5 s1 and you will order an EMG and in this case you will have abnormalities and innovation in the proximal muscle paravertebral ingredients biggest minimus this energy should be used also for the also neutral neuropathy slide the

**[34:18]:** distance shattuck nerve to be uncommon for the pudendal nerve for the gluteal for the patella femoral cutaneous nerve also the ultrasound guided injection of rule why the diagnostic injection will be used to assess the diagnostic of facet or genic buttock pain of clinical neuropathy of pudendal neuropathy and of the posterior femoral cutaneous Europa now if we suspected multiple sclerosis with the clinical assessment in the story for sure as for premature and analyzes and brain MRI that will confirm this diagnosis now for the non dgs cause of buttock pain if it's a secure yard joint do an MRI that will show you information insecure ill items or degeneration is too artritis if it's an austere trial test with a silver Taranto's each ray will be diagnostic with a painting of austerities the CT scan will be more specific and sensitive for lab relation suspicion to an MRI or a CT scan if it's an entropic issue

**[35:35]:** ultrasound MRI and use this ultrasound and graded injection for the trunk a trochanteric bursitis now some words to finish this presentation about the specific treatment of the PS because here they do exist a consensus on the treatment algorithm the first step treatment should be the conservative treatment with physical and medication in case of failure after six week you can use ultrasound guided injection in case of failure after quantity injection you can use bottling of toxin injection and all the in case of value of those three first step you should consider surgical decompression and neural eise's for the conservative treatment of the specific PS you should consider the goals if it's an overuse you should educate the patients tropez stopping the triggering activities changing the rest position and others for the nerve entrapment using aunt in front area vitamin B gabapentin pregabalin for the neuropathic pain for the piriformis spasm you can use muscle relaxant medication

**[36:48]:** you can use physical therapy techniques like different think of stretching relaxing deep massage and extending those technique to neighboring muscle like unstring never forget to do head motion and to do eventually static nerve motion gliding motion and also use the manual therapy or Super T as checkup and also as we harmonization locally and distant now for the therapeutic injection you can use anesthetic and cortical it always under draw some guidance for the static now safety and also for efficiency even if this efficiency is different in different studies there is one consensus telling that the first injection should be an anesthetic injection because anesthetic could confirm the diagnosis and also because anesthetic injection only is frequently as efficient as anesthetic and cortisol in case of failure you can use potent toxin that has been shown to be more efficient than other injection even if there is also side effect for the surgical decompression modern open technique

**[38:10]:** now we use the me open 1002 me or endoscopic 1002 be our new releases with very good success rate Fishman talking about 80% success rate on the 20% failure or the 3 first treatment thank you

**[38:36]:** Thank You Terry it was great and it showed that the the this syndrome which is probably not very known by the majority of people oh just illustrate that there are multiple cause of buttock pain and sciatica

**[38:56]:** so why this place for mr. masala Sandro is so famous I mean what do we talk more about this one I

**[39:14]:** think there is two different reasons first it was the first described cause of intrapreneurs optic nerve that is not coming from the spine I mean when you have Shetty Kappa pain the first thing you have to think about is for sure the radical body but many times when you have a really cool party us for an MRI and this MRI is not contributing you have to know that only 15% of the MRI are positive in case of so in the case you have to search a bit further and the first described cause was the playfulness so that's the first reason the second reason is that out of the radical but it the most frequent reason remains the piriformis muscle in the different studies we talked about to to ensured ratio of the performance codes so it's a frigging it's a freakin pathology more freakin that we could imagine I think yes I think this Association

**[40:24]:** see Attica pain buttock pain and the MRI is not contributed huge think about this I think and you have to do this differential diagnosis and it's maybe another reason why it's a little bit so famous because the differential diagnosis is not easy to do multiple codes and the differential is sometimes difficult because I didn't talk about one difference differential diagnosis is the most difficult to assess it's what we call the double crush syndrome what is the bar crush the best example is to have association of shattuck nerve lesions in the spine dupa tl5 for example and a second lesion on the shaft nerve under debris Falls so it's a double nation of the static nerve two levels and it's very difficult to assess this even by energy and you mentioned already but just to confirm when there is a patron is Sandro there is one of the two sign which is buttock pain and sciatica

**[41:34]:** but can we have you told us but it's important can we have can it be a cause of drop fruit without pain usually the pure the pure you should have buttock pain and you should have salad like si si si si data-collecting rarely drop food because it's more demyelination that axonal loss but I think that if you have a drop food without pain you should think first about common peroneal neuropathy at the federal secondly the relativity l5 and if there is not contribution of the Mariah for the spinal and nmg because the energy will be diagnosis for the common peroneal nerve so to an AMG negative do an MRI of the spinal the spine if both are negative think about the top pain and one thing you mentioned very clearly and interesting is actually didn't remember that when you said that the patient when he standing the first thing when you look at the patient is standing in the external rotation yeah so you said that it could be a contractor yes could it be as well the

**[42:59]:** fact that you know if you are in internal rotation you compress a little bit because you put in the passive tension so could it be a sort of reaction to untight the and to release the site a solely in case of performance in only from syndrome this external rotation you can see in your patient in the involved the side is related to the contract the contraction rupiah give this unilateral external rotation now is it a reaction for sure if your piriformis muscle is painful you will try to be in external rotation to avoid to stretch this painful tree from this muscle yes soon so your message is clear EMG is

**[43:58]:** so we cannot this of field from a sunroom without specific EMG done by someone like you because I understand quite specific so it's mandatory so it's it's mandatory for this kind of ramp for different vision it's not 100% sure that this EMG will assess the positive diagnosis of performance syndrome because it's only based on this edge reflex and this edge reflux it's not perfectly sensitive such sure and it's not perfectly specific and even if you don't have because many times we cannot record any edge reflex for different reason uch reflex it's only the objectification of the Achilles reflex so in some people they are born without this it really sells s1 reflex Achilles tendon reflex so when we don't have any edge reflex we cannot say anything but the audio interest of this energy it's also to exclude the radical region with paravertebral gluteus medius minimised innovation that if you haven't used you know that

**[45:16]:** it cannot be performance muscles or if you assess that problem is a compression at the figurehead so there is different method to assess a little bit level of the difference of the city I think it's important to mention right open your eyes the question is a good evening if you have an epidural infiltration to treat a lumbar pain can we can can it be interfering with peripherals and roll some tones first epidural injection is not a treatment for lumber Bay and if we have to do an injection only for low back pain it's because it's a facet of unique low back pain so it's low back pain coming from the facet and we can inject facet okay but epidural injection it's to treat radical party so France

**[46:16]:** the others that injection is not for loca it's for radical so if we inject an epidural for radiculopathy if the C attica is coming from this ready to potty this route impingement there is no contraindications and there is no modification of the relation between the static nerve and the p.m. now if you do any patrol and sciatica pain is not coming from the spine but is coming from the p.m. at San relationship for sure the period will not be efficient but there is no consequence

**[46:59]:** I have two questions from Donna first of all I will go to the treatment because you know otherwise I will miss some so first of all on the medical treatment which muscle do you inject with botulinum toxin and at watch with rosacea so which muscle the one that has been confirmed by the anaesthetic diagnostic injection to be responsible of the impingement that's as simple as that and okay we historically we injected the piriformis muscles but more and more we consider eventually to inject also the gemenese i complex which is more and more involved as schools of this Shattuck nothing trouble how many dachshund usually we use the toxin ah and the dosage is variable between 100 and 200 UI and into the mass and

**[48:07]:** a question about the treatment what exactly are the structure that are released during neuro lysis and what is the time to consider the conservative treatment should be us faith so conservative treatment six week if you have failure after good conservative treatment using technique I was describing you have to go to the next step which is injection okay so what muscle do we have to release release and also don't forget the new releases of the muscles the one who which is compressing the optic nerve so you have to base your decompression on the image MRI on the LMG if there is but the limbs you will not tell you if it's the reform is or the gemenese or a complex but also the ultra structure modification at Ameren could be useful and also the diagnostic and therapeutic injection if you have relief of pain when you inject a general so I compared release the German soil

**[49:14]:** complex and that's the reason why we more and more use the endoscopic surgical release because with this unless copic treatment we can follow the static nerve all along is tragic to see where is eventually decompression with this diabolo effect and this I did not this edema proximally we see that very well when we do a autoscopic assisted the repair of the proximal end up showing the expect country now for some question from dinner so to question one question I mean okay we read the question as it is in your opinion what is the most effective and so stiff test for diagnosis of for mrs. Andrew and any big sign so first of all we go in the clinic we effluence were a take-home message what is a mnemonic sign which one is it so it's simple the nominee sign doesn't exist there's not so when you read the result REE all the ways when we talk about piriformis syndrome we talk about exclusion create diagnose it's as simple as that so it's a combination of tests you have to use you have to think

**[50:34]:** about the story you have to do a clinical assessment and you have to use different investigation depending on the result of the cases but there is no pattern ohmic sign or positive diagnosis with anything so I think the most useful first test a clinical assessment probably is the test knowing that it's not a mechanical pain that you use it's the posture bed so you have to maintain this fair position for at least one minute before to say that okay there is no but a pain there is no shattuck like pain elicited by this position and so the question began but it's important to keep a good message and clear what is the most effective and sausage test for the dinies again

**[51:30]:** very misunderstood maybe maybe it was only on the clinical side I thought it was the question about complementary I mean the imaging has a smaller EMG I did by the way this is a question that I can jump on this question principle I would like you to tell us more about the MRI is it possible to have an absolutely normal sighting on the very good quality MRI if there is a period of receptor or do you have to use a sweetie stuff I think that it depends on the intensity of the ball if you have only a small irritation of the shutters now you can have very high level of pain distally in the shuttle so in that case the nmg could be completely negative the run could be and the meringue could be completely negative it will maybe show you some change in the relationship between the p.m.

**[52:33]:** and the Sun yes but you cannot offer to diagnose only on this basis that's the reason why if you do a clinical assessment with a fair test positive with the also specific test positive and if you use also this list of 12 criteria that gave us Michelle so it's a bundle of clues that - gasps you confirm or after a little bit more the diagnosis I think that's the best to do and in that case use also the diagnostic injection that's a good tool also during the injection if you really pain all the buttock pain and the static like pain only doing an injection in the piriformis okay you know what's going on can we can we cut this muscle without near big side effect this is the frame yes but first there is multiple external rotator muscle it's a different stick if you cut muscles it's it's like a straight it's like a strain

**[53:38]:** of the muscles okay if you have an accident of your muscles you will heal so it's a little bit the same here and even the rehabilitation after this kind of decompression is very very fast today after the patient is should be standing and it has to work as soon as the pain low working so it's not a very very big problem to release the shutting off cutting this nerve there this muscle also ones we will not do it Otto Otto petty surgeon because so to be a surgeon I know that we so John my question yeah we know that we when we do a total hip arthroplasty with using a posterior approach the period form is the one that we we should preserve by the way but if it is damaged it's not a huge effect not a big issue no no but knowing that we cut the external rotator we can clearly I think

**[54:43]:** it was great really a good weight first of all to remind the clinic imaging assessment EMG and treatment of this so-called piriformis Sandro it was in the same time a good good way to do a sort of current concept on how to manage the buttock pain with Jessica and I hope people will enjoy it that I'm sure they will read listen and watch sure because there are so many times that it's good it's good we watch together to hold the complementary you have two different sentences and if I if I understand your message as a take-home message is that we need to think about this and Rome thank you and if you have any doubt about the origin of the shutting of entrapment go back to YouTube see at this differential diagnosis list sync also go to this criteria list of Michelle because I think it's a useful tool and and do the job and

**[55:59]:** at the end of the because it's a question from tube and what is the exact role of freezer sharp in your treatment is the first step treatment first time first a treatment Michelle did a study for his PhD after six week of this treatment only fidgets repeat treatment there is around 60 65 percent good and very good result okay this result is maintained after 12 week around 50/50 percent yes and the remaining 50 go through injection but only with filter between the earth good and pretty good result in about 50% of the case so for sure I think it's a good conclusion

**[56:48]:** so for people who want to have more information go back to this video if you want which will be always available in to our channel thank you again clearly so now this live broadcast the export forum you know that we stopped every week because it was exceptional break and a situation of the cove in lockdown and now I know that people are going back to the normal activity progressively so we will go to different ways with every two weeks so it means to our next the exponent forum live broadcast will be in two weeks and it will be with that we you know our specialist of hand surgery and the Parliament and he will talk about the topic that we love because you know you have civilian see photo to after the the correct energies and the correct management of the finger sprains and dislocations so see you in two weeks thank you again clearly

**[57:55]:** and it was great thank you hope you see two weeks I will