Welcome to the June 2011 Case Study from the Institute for Nerve Medicine.

This patient has been suffering from a complex pelvic and lower extremity pain syndrome.

This is a 34-year-old, left-handed female who reports left sided joint pain radiating down the posterior lower extremity, as well as right groin pain. The patient states that when she was in college she suffered a fall on her backside while participating in a student rally, landing on a hard gym floor she immediately experienced stabbing lower back pain. In addition, about two years ago while taking a yoga class, she developed a sensitive area in the right groin region. Along with the pain sensitivity, she has sensations of intermittent weakness in the lower extremity. This was managed over time and she was able to have a normal life with minimal pain until recently when she developed persistent stabbing pain symptoms in the left thigh and joint area.

The symptoms have begun to radiate along the outer thigh, down and around to the back of the knee. She has had lower back injections, SI joint injections, and radio frequency ablation. These treatments have only led to short-term relief so the patient has also tried physical therapy, acupuncture, chiropractic and massage treatment with mild improvement. She is unable to tolerate lying flat and spends most of her time in a partially- seated position. Currently she rates her pain level as 8 out of 10 and continuous.

Physical examination and MR Neurography imaging showed involvement of the Piriformis muscle as well as the superior gluteal nerve and the obturator internus nerve. She had an excellent response to her MRI-guided procedure, which involved treatment of the Piriformis muscle, as well as the superior gluteal nerve, trochanteric bursa and obturator internus nerve. In addition to diagnostic confirmation, the MRI guided interventional treatment provided long term relief but after about six-and-half months of pain relief the symptoms recurred. Because of the successful therapeutic treatment, the Piriformis pain location and specific nerve locations were accurately identified and the surgical site was evident. After weighing her treatment options between a traditional Piriformis surgery offered by an insurance contracted doctor on the East Coast, the patient opted to go forward with a minimal access Piriformis surgery in Los Angeles with Dr. Filler.

Minimal access Piriformis operative procedure: Using the high density images from MR Neurography and the real time images from Interventional MR surgical planning, a 3-cm incision was made based over the tip of the greater trochanter, proceeding medially and superiorly at a 45-degree angle. This is tiny in comparison to a traditional Piriformis surgery.

Unlike the bigger Piriformis surgeries that are akin to major hip surgery, the minimal access surgery is less invasive and is highly effective with about 85% of patients objectively reporting good results versus traditional surgery outcome reporting a success rate of 5% to 10%. The minimal access surgery approach is safer and the recovery is rapid; patients usually get over the surgery within a week and then experience a progressive recovery within 90 days post surgery.

At four month’s out from her minimal access Piriformis Surgery this patient sent emails to Institute for Nerve Medicine staff for making her visit both enjoyable and memorable. In expressing gratitude to Dr. Filler, she writes, "I am looking forward to living my life to the fullest and have never felt better. The plane ride home was the first flight I have taken in years without pain. Thank you for everything but mostly thank you for making me pain free!"


MR Neurography image from Case Study



This MR Neurography image captures the normal spinal card and nerve root, along with sciatic nerve irritation at the Piriformis muscle.


Anatomic Specimen Image Depicting Sciatic Nerve Anomaly



This anatomic specimen image shows an anomaly in which the sciatic nerve coalesces from three separate trunks distal to a bifid Piriformis with the superior trunk passing between the bifid muscle bellies. Image copyright JW Thomas Byrd.