Piriformis Botox?

[Ferrismonk]

Does anyone do this? If so, what's your technique? I have a young patient with history of SI fusion with terrible piriformis issues. She gets great relief with piriformis local/steroid injections, but they only last about 3 months and I'm looking for something that will last longer.

I've talked to my Botox rep who won't say much due to it not being an official approved procedure. :/

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[lobelsteve]

Lasts 3 mo too

 

[willabeast]

Do like a normal piriformis injection but add botox. Be sure to document discussion regarding botox risks. I think once my injection leaked onto the sciatic nerve, lidocaine made patient weak for 30 minutes. I always used fluoro and dye to document spread.

 

[Ferrismonk]

Do like a normal piriformis injection but add botox. Be sure to document discussion regarding botox risks. I think once my injection leaked onto the sciatic nerve, lidocaine made patient weak for 30 minutes. I always used fluoro and dye to document spread.

How many units do you inject?

 

[willabeast]

try this. Piriformis Syndrome:Anatomic Considerations, a New Injection Technique, and a Review of the Literature | Anesthesiology | ASA Publications
i skimmed it, seems like a pretty good article. i remember a lot of my colleagues used EMG (i did not).
i also remember 100 units as the dose of Botox but have been retired over 2 years and I do not have access to my records anymore.

 

[Gauss]

I've talked to my Botox rep who won't say much due to it not being an official approved procedure. :/

used to be cost prohibitive as cash only, not billable. Then came along the LE spasticity indication for botox
But I doubt you'll be blown away by the results

 

[epidural man]

I use botulinum toxin in the piriformis not infrequently.

I do it only after a diagnostic injection gives temporary relief.

I use Xeomin 50U.

I do them under ultrasound but fluoro seems to work just as well.

 

[Biohazard685]

Same as regular piriformis. One attending would use a nerve stim, advance needle until motor response, then give touch of contrast and local until motor response diminishes, then the Botox.

 

[thecentral09]

I use botulinum toxin in the piriformis not infrequently.

I do it only after a diagnostic injection gives temporary relief.

I use Xeomin 50U.

I do them under ultrasound but fluoro seems to work just as well.

curvilinear or flat ultrasound?

 

[Gauss]

curvilinear or flat ultrasound?

depends on body habitus - typically curvilinear but thin especially runners/athletes you can easily use a straight probe

https://www.archives-pmr.org/article/S0003-9993(06)01319-0/pdf?code=yapmr-site

 

[epidural man]

curvilinear or flat ultrasound?

Always curvilinear for me. I don’t need the fine detail I get with a flat probe.

 

[clubdeac]

I always do 50 units

 

[OutofNetwork]

use 50U of botox with fluoro guidance

 

[painfree23]

use 50U of botox with fluoro guidance

landmarks for fluoro guidance?

 

[OutofNetwork]

landmarks for fluoro guidance?

Line from greater trochter of femur to lateral border of sacrum (inferior to SI joint)

 

[DOctorJay]

landmarks for fluoro guidance?

http://www.painphysicianjournal.com/current/pdf?article=OTk0&journal=43

 

[RubicksCube]

What ICD code is acceptable to get approval for piriformis injection with botox?

 

[soccrwz]

Go to 2:30 seconds or so, you can see the piriformis quite well with ultrasound, and if having difficulty rotating the leg can help. U/S is very simple, fluoroscopy is faster, but if you really want IM for botox, U/s can help you visualize this better. We used to use 50 units for this.

I took a screen shot of another presentation on codes below. But I haven't confirmed the codes in awhile

 

[RubicksCube]

Go to 2:30 seconds or so, you can see the piriformis quite well with ultrasound, and if having difficulty rotating the leg can help. U/S is very simple, fluoroscopy is faster, but if you really want IM for botox, U/s can help you visualize this better. We used to use 50 units for this.

I took a screen shot of another presentation on codes below. But I haven't confirmed the codes in awhile

thank you kindly

 

[au bon pain]

Bumping to see if folks have recent experience with this. Have a patient I’m thinking about offering this to as only gets 1-2 weeks of relief from traditional injections.

I inject the piriformis under fluoro with contrast. All the papers I see rec 100u but I was thinking of trialing 50u to stay on the safe side.

What are other folks doing?

 

[soccrwz]

How do you get the botox covered, I’d with about spill over to the sciatic many variations with piriformis and sciatic location

 

[oreosandsake]

Learn how to do this under ultrasound

See the sciatic which is variable and avoids the other muscles which are deeper and may give you similar Stim results

 

[Orin]

How do you get the botox covered, I’d with about spill over to the sciatic many variations with piriformis and sciatic location

I believe the covered diagnosis you're looking for is G24.9 dystonia, other which can map to a focal dystonia of non-central origin.

Agree with U/S guidance

 

[au bon pain]

How do you get the botox covered, I’d with about spill over to the sciatic many variations with piriformis and sciatic location

I agree staying away from the sciatic is of course ideal—but at the level of the piriformis, what specific neuromuscular junctions with the sciatic at the business end would be of concern for inadvertent spill over?

Thanks for your and others comments.

Just did it with both us and fluoro guidance after reviewing this paper:

https://www.painphysicianjournal.com/current/pdf?article=NzQ0Ng%3D%3D&journal=142

Fwiw, the tip of rotating the leg is super helpful to most clearly highlight the muscle on sono.

 

[cowboydoc]

I agree staying away from the sciatic is of course ideal—but at the level of the piriformis, what specific neuromuscular junctions with the sciatic at the business end would be of concern for inadvertent spill over?

Thanks for your and others comments.

Just did it with both us and fluoro guidance after reviewing this paper:

https://www.painphysicianjournal.com/current/pdf?article=NzQ0Ng%3D%3D&journal=142

Fwiw, the tip of rotating the leg is super helpful to most clearly highlight the muscle on sono.

Sciatic fibers traverse through the piriformis in something like 15% of cases.

 

[au bon pain]

Sciatic fibers traverse through the piriformis in something like 15% of cases.

Yup. It sounded like the other poster was describing concern if Botox came into contact with the sciatic at that level. While of course it’s best to stay well clear from the nerve for a variety of reasons, mechanistically it doesn’t seem like botox should have any meaningful impact on the nerve at that level since it’s passing through, rather than innervating anything nearby. But maybe I’m mistaken?

 

[cowboydoc]

Yup. It sounded like the other poster was describing concern if Botox came into contact with the sciatic at that level. While of course it’s best to stay well clear from the nerve for a variety of reasons, mechanistically it doesn’t seem like botox should have any meaningful impact on the nerve at that level since it’s passing through, rather than innervating anything nearby. But maybe I’m mistaken?

Yes. Concur. As long as the needle doesn’t hit the sciatic, botulinum locally near the nerve shouldn’t have a negative impact on distal musculature.

 

[soccrwz]

 

[au bon pain]

View attachment 377655

Quite aware of this. Did you have a specific concern of Botox coming into contact w/sciatic at this level, or was your comment more about avoiding zinging the nerve in general?

 

[nvrsumr]

I always bill piriformis injection with us guidance and local as sciatic nerve block… twofer

 

[Ducttape]

are you billing for 2 procedures while doing 1 procedure? id be a little worried about that...

 

[MitchLevi]

The dreaded piriformis pain disease.

 

[nvrsumr]

only billing 64445 +76942