Back Pain-Sciatica: Think Sacroiliac Joint and Piriformis compressive Sciatica
posted by : Dr. Barnetton: 21 April, 2019
Up to 28% of discectomies in the U.S. for bulging discs and leg pain are performed leaving the patient with the same symptoms. Later we find that the presentation was Sacroiliac joint instability and Piriformis compression of the Sciatic nerve. This presentation accounts for easily one third of my practice. I always hope I get to them before surgery to help treat, but at the least, help clarify the diagnosis. These patients have usually had extensive inappropriate treatment with epidural injections, finally ending up with a Surgeon. Fortunately my local surgical colleagues are familiar with the differential diagnosis.
The Sacroiliac (SI) joint is often overlooked. Pathology is not easily identified with the usual MRI, X-ray workup. There are many stress tests to identify the SI joint as a pain generator, however in my experience, two simple methods are the most revealing, the “Fortin finger test” and bracing the pelvis with an SI brace.
Left: Sacroiliac Belt.
Right: Fortin finger test over the SI ligaments
The Piriformis is the only muscle to compress the Sciatic nerve. Think “fat wallet” or “pain in the butt syndrome”. It attaches to the Trochanter and is often accompanied by Trochanteric bursitis and overlying Iliotibial band syndrome. (ITB syndrome). Injection therapy combined with bracing and stretching the piriformis is often curative. If it is not, we have had great success with Minimally invasive S.I. fusion using S.I. Bone company’s iFuse system in patients not adequately treated conservatively.