Piriformis Syndrome Surgery

Surgery for piriformis syndrome is rare and is usually considered the last option when non-surgical treatments have failed to provide satisfactory improvement in buttock, hip, and leg pain.

Piriformis syndrome surgery is elective, meaning that it is up to the patient to decide if he/she would like to choose surgery as the treatment option. It is essential to discuss the risks, benefits, and surgical alternatives with the surgeon before considering surgery for piriformis syndrome.

Research indicates that around 80% of patients undergoing piriformis surgery experience pain relief and reduced symptoms. ¹ Han SK, Kim YS, Kim TH, Kang SH. Surgical Treatment of Piriformis Syndrome. Clin Orthop Surg. 2017.9(2):136-144. http://doi.org/10.4055/cios.2017.9.2.136 ^{, 2} Filler AG, Haynes J, Jordan SE, et al. Sciatica of nondisc origin and piriformis syndrome: diagnosis by magnetic resonance neurography and interventional magnetic resonance imaging with outcome study of resulting treatment. J. Neurosurg. 2005.2(2):99-115. http://doi.org/10.3171/spi.2005.2.2.0099

When Surgery May be Indicated for Piriformis Syndrome

Surgical treatment of piriformis syndrome is indicated when:

• Non-surgical pain management, such as medication and physical therapy, has been tried for several months or longer without satisfactory improvement.
• The symptoms and signs of piriformis syndrome have progressed over time.
• The patient's quality of life is considerably affected due to buttock and hip pain, and there are significant functional limitations.
• Radiographic imaging, such as a computed tomography (CT) scan or an magnetic resonance imaging (MRI) scan confirm compression or injury to the sciatic nerve by the piriformis muscle. Additionally, anatomical or structural variations of muscles or nerves causing piriformis syndrome that are confirmed through radiographic imaging may need surgical intervention to control the symptoms.

Surgeons may also conduct other diagnostic tests, such as electromyography (EMG) and somatosensory evoked potential (SSEP) tests to evaluate the health of the piriformis muscle, sciatic nerve, and other pelvic nerves before considering surgery. ¹ Han SK, Kim YS, Kim TH, Kang SH. Surgical Treatment of Piriformis Syndrome. Clin Orthop Surg. 2017.9(2):136-144. http://doi.org/10.4055/cios.2017.9.2.136

Types of Surgeries for Piriformis Syndrome

Two common surgical procedures for piriformis syndrome include sciatic nerve decompression and piriformis muscle release. Both these procedures aim to relieve pressure on the sciatic nerve and reduce the symptoms of piriformis syndrome. The specific surgical technique for treating piriformis syndrome depends on the underlying cause of piriformis muscle pain and the severity of the symptoms.

Sciatic nerve decompression

Sciatic nerve decompression surgery involves releasing the compression on the sciatic nerve by removing or moving the surrounding structures that are compressing the nerve. This procedure can be invasive, as it may involve removing a portion of the bone or other structures surrounding the sciatic nerve.

Piriformis muscle release

Piriformis muscle release is a type of surgery that involves removing or releasing a portion of the piriformis muscle to relieve compression on the sciatic nerve. This procedure is typically performed using minimally invasive techniques, with small incisions made in the buttock area.

Open surgery vs endoscopic surgery for piriformis syndrome

Both sciatic nerve decompression and piriformis muscle release can be performed endoscopically and through open surgical procedures. The endoscopic approach typically results in lesser damage to the soft tissue and muscle, which may cause lesser post-surgical pain and a shorter recovery time. ³ Jackson TJ. Endoscopic Sciatic Nerve Decompression in the Prone Position-An Ischial-Based Approach. Arthrosc Tech. 2016.5(3):e637-642. http://doi.org/10.1016/j.eats.2016.02.020 Open surgery may be indicated when more anatomic structures are involved, and it may carry a higher risk of post-surgical complications, such as hematoma formation, infections, and long rehabilitation time, compared to the endoscopic approach. ⁴ Ham DH, Chung WC, Jung DU. Effectiveness of Endoscopic Sciatic Nerve Decompression for the Treatment of Deep Gluteal Syndrome. Hip Pelvis. 2018.30(1):29-36. http://doi.org/10.5371/hp.2018.30.1.29 ^{, 5} Coulomb R, Khelifi A, Bertrand M, et al. Does endoscopic piriformis tentomy provide safe and complete tendon release? A cadever study. Orthop Traumatol Surg Res. 2018.104(8):1193-1197. http://doi.org/j.otsr.2018.02.018

Who Performs Piriformis Syndrome Surgery

An orthopedic surgeon performs piriformis syndrome surgery, and a multidisciplinary team composed of a physiatrist, physical therapist, and primary care physician will typically be involved in the pre-and-post surgical processes. ⁶ Vij N, Kiernan H, Bisht R, et al. Surgical and Non-surgical Treatment Options for Piriformis Syndrome: A Literature Review. Anesth Pain Med.2021.11(1):e112825. http://doi.org/10.5812/aapm.112825

Long-Term Outcomes of Piriformis Syndrome Surgery

Research indicates that piriformis surgery may provide substantial relief from piriformis syndrome symptoms. Pain relief is usually long-lasting, with most patients experiencing complete resolution of their symptoms for several years after the surgery. ⁷ Fahmi A, Rahmadhan MA, Aprianto DR, Subianto H, Turchan A. Complete resolution of recurrent piriformis syndrome after piriformis resection with 3 years follow up: A case report. International Journal of Surgery Case Reports. 2020.77:576-579. http://doi.org/10.1016/j.ijscr.2020.11.099

A large study evaluating the post-surgical outcome of 239 patients treated for piriformis syndrome found that1:

• Around 83% of patients who underwent surgical procedures experienced satisfactory results.
• No post-surgical complications were observed during the 1-year follow-up.

As with any surgical procedure, there are potential risks and complications involved, and patients should discuss these risks with their surgeon before deciding on surgery.

Risks and Complications of Piriformis Syndrome Surgery

Potential risks and complications of piriformis syndrome surgery include ¹ Han SK, Kim YS, Kim TH, Kang SH. Surgical Treatment of Piriformis Syndrome. Clin Orthop Surg. 2017.9(2):136-144. http://doi.org/10.4055/cios.2017.9.2.136 :

• Bleeding. Damage to arteries may cause localized bleeding and blood pooling within the buttock's soft tissues. A hematoma or blood clot may form inside the artery, blocking the blood supply to vital tissues and organs.
• Infection or abscess formation. Improper sterilization of the surgical site or improper handling of surgical instruments can lead to infection and pus may accumulate within the soft tissues at the site of the surgery.
• Nerve damage. Damage to the major pelvic nerves may cause abnormal sensations or loss of sensation in the buttock and hip area, which may be transient or permanent depending on the severity of nerve damage.
• Scarring. Scarring or adhesions may occur at the surgical site, which may delay healing and cause pain after surgery.

It is possible that piriformis syndrome symptoms and signs may sometimes recur after surgery, requiring additional treatment.

How Long Does It Take to Recover from Piriformis Syndrome Surgery: What to Expect

The recovery process after surgery varies for each individual and depends on factors such as the extent of the procedure, overall health of the patient, and the rehabilitation program. Patients may go home the same day or the next day after surgery if minimally invasive procedures were used. If open surgical techniques were used, a hospital stay of 2-4 days may be necessary.

Typically, it takes several weeks to months to fully recover from piriformis syndrome surgery. During the initial recovery period, the patient may experience some pain and swelling, and physical therapy is usually recommended to help improve strength and flexibility.

Resuming physical activities after piriformis syndrome surgery

Walking a few steps may be initiated a few hours after surgery with guidance from a physical therapist, and light physical activities, such as walking short distances or getting in and out of bed without assistance may be resumed the day after surgery.

Watch 2 Walking Tips for Piriformis Syndrome Video

Activities to avoid after piriformis syndrome surgery

During the recovery process, it is crucial to avoid certain activities that could delay healing at the surgical site. These activities include:

• Prolonged hot baths and showers
• Intense physical activity
• Swimming

Driving or operating heavy machinery is not advised when opioid pain medications are prescribed. These activities may be resumed when pain medication has been tapered and stopped.

Depending on the patient’s general health and healing, the surgeon provides specific instructions on when it will be possible to return to normal activities and exercise.

Alternatives to Piriformis Surgery

If surgery is not possible or desired, minimally invasive treatments or complementary and alternative medicine (CAM) may be used to treat piriformis syndrome in addition to continuing with standard first-line treatments.

A few surgical alternatives to piriformis syndrome surgery include:

Piriformis injections

Injections containing anesthetics, corticosteroids, and/or botox (botulinum toxin) may decrease inflammation, swelling, and spasm in the piriformis muscle, reducing pain and symptoms of piriformis syndrome. Injection treatments are generally administered by a physiatrist or pain management specialist and may carry potential risks, such as bleeding, infection, and nerve damage. While some studies have favored injection treatments for relieving the symptoms of piriformis syndrome, others have not shown long-term pain relief with this intervention. ⁶ Vij N, Kiernan H, Bisht R, et al. Surgical and Non-surgical Treatment Options for Piriformis Syndrome: A Literature Review. Anesth Pain Med.2021.11(1):e112825. http://doi.org/10.5812/aapm.112825

Manual therapy

Manual therapy performed by a physical therapist, chiropractor, osteopath, or licensed massage therapist including soft tissue mobilization and myofascial release may help improve blood circulation to the buttock area and foster healing in the sore muscles and other soft tissues. Research indicates that manual therapy may help relieve pain, tightness, and inflammation in the piriformis muscle. ⁸ Kukadia HA, Malshikare A, Palekar TJ. Effect of Passive Stretching v/s Myofascial Release in Improving Piriformis Flexibility in Females – A Comparative Study. Indian J Physiother Occup Ther. 2019.13(4):57-61. http://doi.org/10.5958/0973-5674.2019.00132.1

Active release techniques

Active release technique is a specialized form of manual therapy that involves applying direct pressure to the inflamed or sore muscle while moving it through its full range of motion. The active release technique aims to break up fibrous tissues and adhesions that may be causing pain and restriction in the muscle. ⁹ Rehamn AU, Khan LG, Khalid M, et al. Comparison of Active Release Technique and Post Isometric Relaxation in Patients with Piriformis Syndrome. Pak. J. Med. Health Sci. 2022.16(5):683-685. http://doi.org/10.53350/pjhms22165683 This treatment may help relieve piriformis syndrome pain caused by fibrous tissue adhesions or a tight piriformis muscle.

Physical therapy focused on nerve gliding exercises

Nerve gliding exercises are a type of physical therapy that is designed to help entrapped nerves, such as the sciatic nerve in piriformis syndrome, move freely and reduce the amount of compression the nerve is experiencing from the offending muscle. These exercises involve controlled movements of a nerve to improve mobility and reduce inflammation. ¹⁰ Siraj SA, Dadgal R. Physiotherapy for Piriformis Syndrome Using Sciatic Nerve Mobilization and Piriformis Release. Curseus. 2022.14(12):e32952 http://doi.org/10.7759/cureus.32952

See Piriformis Muscle Stretch and Physical Therapy

A physician can help formulate the right surgical alternative suited for the patient.

Surgery can be an effective treatment for select individuals who have not found relief from non-surgical treatments for piriformis syndrome. Working closely with a physician and surgeon and following their recommendations can help ensure the best possible outcomes and reduction of symptoms caused by piriformis syndrome.