Sarasota Neurology

How many people do you know who tell of back pain that has no cure? Or sciatica or leg pain than doctors cannot find the cause for. They tell you that the MRI scan was normal, back injections of steroids do not help and no medication has relieved their pain. There are tens of thousands of people with back pain and sciatica who never get the right diagnosis despite having several MRI scans and seeing numerous physicians. There is a high probability that these individuals suffer from a condition called piriformis syndrome. Unfortunately piriformis syndrome is frequently misdiagnosed as sciatica.

The piriformis muscle is a triangular shaped muscle that is in the middle of the buttocks. The base of the triangle attaches to the side of the sacrum (tailbone) and the tip attaches to the top of the femur (the major bone in the hip and leg.) An excellent piriformis diagram is found on the Institute for Nerve Medicine website. Injury or sprain to the piriformis muscle causes spasm, which in and of itself is painful. This can cause back pain and buttocks pain. Prolonged sitting will make the pain worse. Walking, climbing stairs or bending can be difficult and painful. The sciatic nerve comes out of the spine, exiting just below the piriformis muscle. In approximately 15% of individuals, the sciatic nerve pierces through the lower border of the piriformis muscle. It is these individuals who are predisposed to developing sciatica with injury to the piriformis muscle. Even without this, a strained, inflamed piriformis muscle will cause irritation to the sciatic nerve thereby causing sciatica.

There is no specific test, MRI or EMG findings in piriformis syndrome. It is a diagnosis made on the basis of getting the patient’s history, unique set of symptoms and detailed physical exam. Ordering an MRI of the back and getting an EMG will only help to exclude other causes of back pain and sciatica. Remember, just because you may have a “bulging disc” or “herniated disc” does not mean that this is causing your back pain or sciatica. Thirty percent of the general population have disc herniation on their MRI scans that are causing no symptoms. Therefore disc herniation does not equal back pain or sciatica Once the diagnosis is made, treatment should be started as soon as possible. The first is to educate the patient about the condition and identify activities that they are doing that irritate the piriformis muscle. Avoiding these activities and holding off on sports activities will help to stop straining the hip muscles. A set of stretching exercises for the back and hip muscles should be done twice daily to relieve the spasm, which will reduce the pain. Muscle Ventures has an excellent diagram and explanation of the piriformis stretch, even with a video.  With this stretching, an anti-inflammatory medication, such as ibuprofen or naproxen, can be taken to lessen the pain and treat the inflammation in the muscle, tendon and sciatic nerve. Physical therapy can have a part in treating piriformis syndrome. It takes a therapist familiar with the condition to effectively provide relief. This in combination with deep neuromuscular therapy in the buttocks region will also help. Injections into the piriformis muscle are rarely performed due to its close relationship to the sciatic nerve and risk of injury to the nerve. Surgery has been tried but it is a major procedure and the effectiveness of this remains in question.

In summary, piriformis syndrome is a condition of strain and injury to the muscle. The sciatic nerve runs immediately below or just exits through the lower piriformis muscle. When injury occurs to the piriformis muscle, the sciatic nerve becomes irritated. This causes lower back and buttocks pain with sciatica. Diagnostic tests can only help in excluding other causes of back and leg pain. Therapy for piriformis syndrome consists of daily stretching, antiinflammatory medication and physical therapy. Affected individuals should avoid activities that aggravate their back pain and sciatica. Healing time can be weeks to months.

Fibromyalgia is a chronic muscle pain disorder that has no underlying identifiable cause. Sufferers have muscle pain, multiple areas of tenderness and fatigue. It is a poorly understood disorder, with many physicians not even acknowledging that it is a real illness. There is , however ample evidence that fibromyalgia is a real condition as it has been estimated that as many as 6 million Americans suffer from this affliction annually. Patients typically see several physicians and become frustrated when all their testing comes back normal. Other accompanying symptoms may include poor sleep hygiene, headache, mental clouding (fibromyalgia fog) and depression. Although this conditions rarely clears, suffers can be treated successfully with a combination of medications and regular exercise.

The FDA has recently approved Lyrica as the first drug specifically for fibromyalgia treatment. Lyrica (pregabalin) was originally approved for treatment of seizures and painful diabetic neuropathy. Based on two large, double-blind studies with 1,800 patients enrolled, the FDA approved labeling for Lyrica to be used in the non-narcotic control of fibromyalgia pain. The exact mechanism by which Lyrica controls the pain of fibromyalgia is not well understood. I have used this drug extensively in my practice to help individuals with fibromyalgia, who have failed other therapies. With FDA approval, more insurance companies will be compelled to cover this otherwise costly medication.

Other medications have been used to help patients with fibromyalgia. Medications in the tricyclic antidepressant family such as amitriptyline, nortriptyline and trazodone have been used with varying degrees of success. Some anti-inflammatory medication may be helpful as well. In combination with medications, it is important for patients with fibromyalgia to get some type of regular exercise that involves muscle resistance. The combination of medications and exercise provide the best hope for controlling the symptoms of fibromyalgia as there is no definitive cure. Mayo Clinic published an excellent summary of fibromyalgia. If you feel that you have this condition, find a neurologist or rheumatologist in your area that has knowledge in treating this condition.

Neck and back pain are some of the most common conditions for which patients seek out medical care. It is estimated that 8 out of 10 Americans will have at least one significant episode of back or neck pain in their life. For many, this can be a recurrent or persistent problem. Fortunately over 90% of the cases can be treated without surgery or other invasive procedures. The most common underlying cause for back pain is poor body conditioning. With our sedentary life styles, it is no wonder that we become deconditioned. Even persons who exercise regularly are prone to developing back or neck pain problems. Without doing specific back and neck stretching and strengthening exercises, we are setting ourselves up to have back pain. Something as simple as bending over to tie a shoe, reaching up in the cupboard or even sneezing can trigger an acute back pain episode. Neck pain is frequently caused by “sleeping wrong at night”, sleeping on a plane or just straining the neck when lifting or playing sports. All of these variations of neck and back pain have as a cause, muscle, tendon and ligament strain. Particularly in the back, individuals will have gradual tightening of the back and hip muscles and not even feel it. Then, when a “minor event” such as coughing occurs, these already tight muscles go into sudden spasm which then is felt as pain. With the acute spasm, patients can have trouble turning their head, bending over, walking and sleeping. Fortunately most of these conditions can be treated without surgery, invasive procedures or even MRI scanning.

In the vast majority of patients, a careful history and detailed physical exam is the basis for developing a treatment plan. Most patients show significant back and/or neck muscle spasm with tenderness. Some patients can have exquisite tenderness in the sacroiliac joint - where the tail bone meets the hip bone. The rest of their neurological exam is usually normal. In these individuals having a CT or MRI scan of the neck or back is not a necessary part of the initial treatment plan. A specifically designed course of hands on physical therapy combined with neuromuscular therapy in combination with self administered neck and back stretching and strengthening exercises will result in favorable outcomes the majority of the time. Sometimes anti-inflammatory medications or muscle relaxants can be of benefit. Narcotics should be avoided as they are habit-forming and do nothing to clear up the pain. In very specific cases, limited use of nerve blocks in the sacroiliac area or lower neck may be helpful. Epidural steroids, for the most part, are not particularly helpful and carry significant complication risks with them; particularly in the neck. For patients that do go on to have MRI studies, it is not uncommon to finding xray abnormalities but these do not necessarily explain the pain that that individual is experiencing. The important message is that the MRI findings must correlate exactly with the patient’s symptoms and neurological exam to have clinical significance. MRI studies of normal individuals without back pain have been done. The results have shown that approximately 38% of these MRI scans showed abnormalities and yet the patients had no symptoms. The conclusion is that just because the MRI scan shows “something”, it does not necessarily mean that that is the cause of your pain.
With careful management and patient cooperation to do the exercises most patients have significant relief with subsequent clearing of their pain within 4-6 weeks. It is then important that patients continue to do their neck and back exercises on a regular basis, as part of their daily exercise routine. With doing this back surgery or neck surgery can almost always be avoided. The most important step in getting better is to seek out care from a knowledgeable, medical physician such as a neurologist or physiatrist who specializes in the non-surgical treatment of neck and back conditions. More information on back disorders can be found at my website or at Spine Universe.