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BRIEF REPORT

Ultrasound-Guided Piriformis Injection: Technique Description and Verication

Jay Smith, MD, Mark-Friedrich Hurdle, MD, Adam J. Locketz, MD, Stephen J. Wisniewski, MD
ABSTRACT. Smith J, Hurdle M-F, Locketz AJ, Wisniewski SJ. Ultrasound-guided piriformis injection: technique description and verication. Arch Phys Med Rehabil 2006;87:1664-7. Piriformis injections are commonly used in the evaluation and treatment of patients presenting with buttock pain syndromes. Because of its small size, deep location, and relation to adjacent neurovascular structures, the piriformis is traditionally injected by using electromyographic, uoroscopic, computed tomographic, or magnetic resonance imaging guidance. This report describes and veries a technique for performing ultrasound-guided piriformis injections. Ultrasound offers several advantages over traditional imaging approaches, including accessibility, compact size, lack of ionizing radiation exposure, and direct visualization of neurovascular structures. With appropriate training and experience, interested physiatrists can consider implementing ultrasound-guided piriformis injections into their clinical practices. Key Words: Buttocks; Injections; Rehabilitation; Ultrasonography. 2006 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation SYNDROME a clinical condition characterized primarily buttock pain and P IRIFORMISby hipbypain andISfeatures ofaccompaniedIttohasa variable degree sciatica.
1-5

been postulated that piriformis syndrome may be a contributing factor in up to 6% to 8% of patients with low back pain.6 Due to a lack of a criterion standard for diagnosis, piriformis syndrome has traditionally remained a diagnosis of exclusion in patients presenting with buttock pain, tenderness to palpation over the piriformis muscle, and a positive response to 1 or more provocative maneuvers.1-5,7 In recent years, when piriformis syndrome is suggested, clinicians have used piriformis sheath and/or intramuscular injections for diagnostic and therapeutic purposes.1-4,7,8 The piriformis is a relatively small muscle lying deep to the gluteus maximus.1-5 Clinical estimation of its dimensions, thickness, and relation to important adjacent neurovascular structures (eg, gluteal nerves, arteries, sciatic nerve) is problematic.1-5,8 Consequently, clinicians have reported the successful use of electrophysiologic guidance,2-4 uoroscopy,1 computed tomography (CT),8 and magnetic resonance imaging (MRI)9 to ensure accurate needle place-

ment for piriformis injections. Ultrasound (US) represents an attractive alternative technique for needle placement during piriformis injections. Modern US equipment provides excellent soft-tissue resolution; identies bony landmarks, nerves, and vessels; and provides real-time visualization of needle passage toward an intended target.10-13 Compared with electromyography, uoroscopy, CT, and MRI, US has no known contraindications, produces no ionizing radiation, does not require contrast, and is well-accepted by patients.10-13 In addition, technologic advances have produced more affordable, compact, high-quality US machines that are accessible to physiatrists practicing in a variety of clinical settings. Our literature review yielded only 1 prior reference7 to the use of US for the placement of piriformis injections. Broadhurst et al7 used US to place local anesthetic into the piriformis muscle in patients with suspected piriformis syndrome. However, they did not provide details regarding the technique, the US machine used was a top-of-the-line model, and the US was performed by a particular radiologist with a special interest in musculoskeletal ultrasound.7(p 2037) Furthermore, although the researchers reported direct visualization of the injectate within the sheath of the piriformis as visualized on dynamic US, they did not attempt to verify the technique using electromyography, uoroscopy, CT, or MRI.7 The primary purpose of this article is to specically outline and provide verication for a US-guided technique to accurately place piriformis injections. It is our opinion that physiatrists and other clinicians skilled in US-guided injections can use this injection in a variety of practice settings and clinical scenarios. METHODS Technique The technique for US-guided piriformis injection was developed using a Toshiba Xarioa cart based US system and was subsequently reproduced using a Toshiba Nemioa cart based US system, as well as a Sonosite MicroMaxxb compact US system. We use the 2 Toshiba machines regularly to perform a variety of diagnostic and interventional US procedures. Each patient is placed in a prone position, and the buttock region is scanned with either a 12-to-5MHz long linear array transducer or a 6-to-1MHz curvilinear array transducer, depending on body habitus and desired eld of view. Pictures included in this article were obtained with the 6-to-1MHz curvilinear array transducer, scanning at 5MHz with tissue harmonic imaging. To optimize reproducibility, piriformis localization is based on bony acoustic landmarks.10-13 The posterior superior iliac spine (PSIS) is scanned by initially palpating it and then placing the transducer horizontally across it. After image optimization, the operator slowly moves the transducer inferiorly while maintaining the horizontal position. The lateral sacrum will be visualized medially and the posterior inferior iliac spine (PIIS) laterally. Slight inferior movement below the level of the PIIS will result in loss of the lateral hyperechoic signal of the ilium as the image plane moves into the greater sciatic notch. With the medial end of the transducer

From the Departments of Physical Medicine and Rehabilitation (Smith, Hurdle, Wisniewski) and Anesthesiology (Hurdle, Locketz), Mayo Clinic College of Medicine, Rochester, MN. No commercial party having a direct nancial interest in the results of the research supporting this article has or will confer a benet upon the author(s) or upon any organization with which the author(s) is/are associated. Reprint requests to Jay Smith, MD, Dept of PM&R, E10 Mayo Bldg, 200 First St SW, Rochester, MN 55905, e-mail: smith.jay@mayo.edu. 0003-9993/06/8712-11008$32.00/0 doi:10.1016/j.apmr.2006.08.337

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Fig 1. (A) Longitudinal view of the piriformis muscle using a 6-to1MHz curvilinear transducer. The piriformis (PIR) muscletendon is visualized as a thin, hyperechoic band passing medial (left) to lateral (right) toward the greater trochanter (GT). The piriformis travels deep to the gluteus maximus (GMAX) as it passes out of the superior greater sciatic foramen, formed anteriorly by the ilium. In this picture, the lateral sacrum would lie just off-screen to the left. (B) Transducer position relative to skeletal landmarks to obtain ultrasound picture shown in gure 1A. Abbreviation: RT PIR LG, right piriformis, longitudinal view (parallel to the long axis of the muscle).

identied lying supercial to the quadratus femoris at the level of the lateral aspect of the ischial tuberosity (g 2). The transducer is placed in an anatomic transverse plane with the medial edge adjacent to the lateral aspect of the ischial tuberosity and the lateral aspect on the posterior aspect of the greater trochanter. In this position, the transducer is parallel to the bers of the quadratus femoris, providing a long-axis view of the muscle. The sciatic nerve is identied as an oval, mixed-echogenicity structure lying supercial to the quadratus femoris and deep to the gluteus maximus. The internal echotexture of the sciatic nerve consists of hypoechoic fascicles surrounded by hyperechoic epineurial connective tissue; the appearance in this transverse view resembles that of a honeycomb. After identifying the sciatic nerve at this level, the nerve can be followed cranially as it passes supercially to the inferior gemellus, obturator internus, and superior gemellus, from caudal to cranial. Thereafter, the nerve will typically move deep to the piriformis muscle. In up to 15% of patients, all or part of the sciatic nerve may pierce the piriformis muscle or emerge superior to it.3,14 The nerve is rescanned in a longitudinal plane for conrmation. Once the nerve is clearly identied and its course and any variations considered relative to the piriformis, the piriformis is once again localized and the skin marked with an indelible ink marker. The buttock is prepared by appropriately draping the area to expose the lateral sacrum and the buttock region in the area of the piriformis, previously identied by US. Thereafter, Choloraprepc is applied to the working area using back-andforth strokes for 30 seconds as per the manufacturers recommendations. The piriformis is then re-imaged in its longitudinal plane with a sterile US transducer cover and sterile US gel. US visualization allows the clinician to place injections anywhere within the piriformis sheath or muscle itself. To inject the sheath, the needle path is typically medial to lateral, parallel to the long axis of both the piriformis and the transducer. After obtaining local anesthesia, a 22-gauge spinal needle is advanced under direct US guidance, traversing the skin, subcutaneous fat, and gluteus maximus; passing lateral to the lateral sacrum; and abutting against the sheath of the piriformis.

remaining at the lateral end of the sacrum, the operator once again optimizes the image. After optimization, the operator will see the following (g 1): (1) medial: the lateral, hyperechoic bony margin of the sacrum; (2) supercial: hyperechoic skin, mixed echogenicity subcutaneous fat, and the hypoechoic marbled appearance of the overlying gluteus maximus; and (3) deep: the piriformis muscle appearing deep to the lateral sacral border (whereas the gluteus maximus is supercial to the sacrum), and traversing from cephalomedial to caudolateral beneath the gluteus maximus. As the piriformis courses caudolateral it can be seen to taper into an echogenic tendinous structure passing supercial to the posterior aspect of the hip. In this longitudinal view, the transducer is parallel to the piriformis bers. Further conrmation of the piriformis may be obtained by scanning perpendicular to the longitudinal axis of the piriformis muscle (ie, transverse view), using Doppler to identify the bordering superior and inferior gluteal arteries, passively or actively rotating the hip to identify the piriformis moving relative to the gluteus maximus, or following the piriformis laterally toward its insertion into the superior greater trochanter. Because of proximity to the piriformis and the potential for anatomic variations, the sciatic nerve is then identied and its course considered.3,14 The sciatic nerve is easily

Fig 2. Transverse view of the sciatic nerve at the level of the quadratus femoris. The transducer is placed in an anatomic transverse plane at the level of the distallateral aspect of the ischial tuberosity. Here, the conspicuity of the hyperechoic sciatic nerve is increased as it passes between the hypoechoic quadratus femoris (deep) and gluteus maximus (supercial). The nerve can then be traced cranially to visualize its passage deep to the piriformis. Abbreviations: LAT, lateral; MED, medial; QF, quadratus femoris; RT QF LG, right side, quadratus femoris, longitudinal view (parallel to the long axis of the muscle); SCN, sciatic nerve. Arch Phys Med Rehabil Vol 87, December 2006

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RESULTS After developing this technique for US-guided piriformis injections, the senior author (JS) easily taught other physiatrists skilled in US-guided procedures its appropriate application. During training, we performed piriformis sheath injections of diluted blue latex on unembalmed cadavers and conrmed placement via dissection. During initial clinical implementation, needles were placed under US guidance in a uoroscopy suite. After needle placement, contrast injection using real-time uoroscopy conrmed accurate needle placement and veried the technique (g 4). DISCUSSION To our knowledge, this is the rst report detailing the technique by which physiatrists can use US to inject the piriformis sheath or muscle as well as providing verication through dissection and uoroscopic contrast control.7 Piriformis syndrome represents a potentially important cause of buttock pain in patients presenting to physiatrists ofces.1-4 When clinically indicated, injections into the piriformis sheath or muscle belly can provide diagnostic information and facilitate recovery.1-4,7,8 Although practitioners have advocated the use of electromyography, uoroscopy, CT, or MRI guidance for these injections, our experience indicates that US provides a favorable alternative for accurate needle placement.1-4,7,8 The US-guided piriformis injection technique described herein has several distinct advantages over electromyography, uoroscopy, CT, or MRI guidance. First, US is an excellent soft-tissue imaging modality. Not only can US easily identify reproducible bony acoustic landmarks, but it can also provide real-time visualization of muscles, fascial planes, important neurovascular structures, and the needle itself.10-13 Second, the use of bony acoustic landmarks makes the technique easy to learn and reliable. As previously stated, the senior author was able to teach the technique to several other physiatrists in a single teaching session. Although we describe the technique moving inferiorly from the PSIS, one may also initially identify

Fig 3. (A) Longitudinal US view of the piriformis during needle placement using a medial-to-lateral approach parallel to the long axis of the transducer. The proximal end of the needle has been digitally enhanced to highlight needle trajectory. (B) Postinjection tenogram at the level of the greater sciatic foramen. Anechoic injectate (FLUID) within the piriformis tendon sheath lies supercial and deep to the hyperechoic tendon. Abbreviations: RT PIR LG, right side, piriformis, longitudinal view; TIP, needle tip.

Typically, the operator can feel when the sheath is contacted and also visually appreciate indentation of the sheath without penetration on dynamic US. The needle is then passed into the sheath (g 3A). To inject the sheath, the clinician simply performs the injection while visualizing the injectate lift the thin, hyperechoic sheath away from the relatively hypoechoic muscle of the piriformis body. Anesthetic is typically anechoic, whereas corticosteroid crystals may be hyperechoic (eg, methylprednisolone) or anechoic (eg, dexamethasone). As the injection proceeds, the injectate will track laterally toward the greater trochanter (see g 3B). To inject the muscle itself (eg, botulinum toxin), the needle is simply advanced through the piriformis sheath and into the muscle belly itself. In this case, US provides a means of depth control to avoid needle passage through the piriformis and into the pelvis. During an intramuscular injection, the injectate may collect as a bolus or track laterally between the multiple slips of the piriformis. After either a sheath or an intramuscular injection, the needle is removed, and the hip may be moved through several repetitions of rotation to provide medial and lateral spread. After a US-guided piriformis sheath or intramuscular injection, aftercare is similar to that after uoroscopic piriformis injection; patients should avoid high-intensity activity and submersion of the buttock region for 24 hours. They may expect some soreness and possibly a slight, temporary postinjection are of symptoms.
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Fig 4. Piriformis tenogram/myogram obtained after needle placement using US guidance and contrast injection under real-time uoroscopy. Contrast ow pattern documents accurate injection.

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the ischial tuberosity and then move superiorly, passing by the ischial spine to enter the greater sciatic notch containing the piriformis. Third, we have reproduced this technique on several different US machines varying in size and cost, suggesting that the procedure may be performed on most modern US equipment, including compact machines that would t into most physiatrists ofces. Fourth, unlike uoroscopy and CT, US can be safely used to guide injections in pregnant patients or those with contraindications to radiation exposure. Finally, although we initially used uoroscopy and contrast to verify the technique, the procedure itself does not require contrast and therefore avoids the costs and potential complications of contrast injections. Several comments regarding training and equipment are necessary. The senior author has been performing a variety of US-guided procedures for over 3 years. As was the case in our practice, we believe that physiatrists should only attempt the US-guided piriformis injection after accumulating adequate training in US-guided procedures and being mentored in the technique itself. Reassuringly, physiatrists benet from a solid musculoskeletal anatomy knowledge base and therefore are optimally positioned to rapidly acquire US skills with appropriate dedication and instruction. We believe that the injection described herein can be successfully executed with a variety of modern US machines and transducers. In general, physiatrists considering this procedure should plan on using a modern US machine capable of scanning at depths of 12 to 14cm or more. As is the case with all US-guided procedures about the pelvis, the depth should be adjusted to identify the bony acoustic landmarks and the frequency adjusted to the highest frequency possible that will adequately image at the target depth. Depending on each patients body habitus, the scanning frequency may fall anywhere between 5 and 12MHz; machines with tissue harmonic imaging will provide physiatrists with a distinct advantage because of their ability to scan at higher frequencies at lower depths. CONCLUSIONS The piriformis sheath or muscle may be accurately injected with modern-day US equipment available to physiatrists practicing in a variety of clinical settings. Experienced physiatrists should consider US guidance for piriformis injections in the appropriate clinical setting.
References 1. Fishman S, Caneris O, Bandman T, Audette J, Borsook D. Injection of the piriformis muscle by uoroscopic and electromyographic guidance. Regional Anesth Pain Med 1998;23:554-9.

2. Fishman L, Konnoth C, Rozner B. Botulinum neurotoxin type B and physical therapy in the treatment of piriformis syndrome: a dose nding study. Am J Phys Med 2004;83:42-50. 3. Fishman L, Dombi G, Michaelsen C, et al. Piriformis syndrome: diagnosis, treatment, and outcomea 10-year study. Arch Phys Med Rehabil 2002;83:295-301. 4. Fishman L, Andersen C, Rosner B. Botox and physical therapy in the treatment of piriformis syndrome. Am J Phys Med 2002;81: 936-42. 5. Papadopoulos E, Khan S. Piriformis syndrome and low back pain: a new classication and review of the literature. Orthop Clin North Am 2004;35:65-71. 6. Hallin R. Sciatic pain and the piriformis muscle. Postgrad Med 1983;74:69-72. 7. Broadhurst N, Simmons N, Bond M. Piriformis syndrome: correlation of muscle morphology with symptoms and signs. Arch Phys Med Rehabil 2004;85:2036-9. 8. Fanucci E, Masala S, Sodani G, et al. CT-guided injection of botulinic toxin for percutaneous therapy of piriformis muscle syndrome with preliminary MRI results about denervative process. Eur Radiol 2001;11:2543-8. 9. Filler A, Haynes J, Jordan S, et al. Sciatica of non-disc origin and piriformis syndrome: diagnosis by magnetic resonance neurography and interventional magnetic resonance imaging with outcome of resulting treatment. J Neurosurg Spine 2005; 2:99-115. 10. Koski J. Ultrasound-guided injections in rheumatology. J Rheumatol 2000;27:2131-8. 11. Koski J, Anttila P, Isomaki H. Ultrasonography of the adult hip joint. Scand J Rheumatol 1989;18:113-7. 12. Koski J, Anttila P, Hamalainen M, Isomaki H. Hip joint ultrasonography: correlation with intra-articular effusion and synovitis. Br J Rheumatol 1990;29:189-92. 13. Qvistgaard E, Kristoffersen H, Terslev L, Danneskiold-Samsoe B, Torp-Pedersen S, Bliddal H. Guidance by ultrasound of intraarticular injections in the knee and hip joints. Osteoarthritis Cartilage 2001;9:512-7. 14. Pecina M. Contribution to the etiological explanation of the piriformis syndrome. Acta Anat 1979;105:181-7. Suppliers a. Toshiba Medical Systems Corp, 1385 Shimoishigami, Otawara-shi, Tochigi, 324-8550, Japan. b. Sonosite Inc, 21919 30th Dr SE, Bothell, WA 98021. c. Medi-Flex Inc, 11400 Tomahawk Creek Pkwy, Ste 310, Leawood, KS 66211.

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