I know there is lots of threads on this topic. My quesiton is if you dont always get the clean myogram, or sausage appears contras pattern (I use 12o clock posisiton the the acetabluar rim) do you always always try and re direct. I feel like I either get it and get the textbook pattern or dont, try and salvage and redirect looking for myogram and things turn into a mess. Any advice on what to do if you dont get optimal contrast pattern but you are exactly were you want in terms of landmarks
Pirifomris injection
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Just do this.
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How deep do you advance needle with this technique?
Fake injection?
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The Pain Source has a tutorial essentially on the article that Steve posted. It is what I use and have good success with the pictures, as far as blob-o-grams, I will try adjusting the needle depth, typically not the overall location assuming I like where I am at. Don't listen to the "fake injection" nonsense. Pretty much everything in pain management has limited evidence-the challenges of treating a subjective experience.
"my physical therapist says i have piriformis syndrome"
there is a huge disc herniation 9/10 times i hear this
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They love the piriformis. And SIJ and thoracic outlet.
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I also use the method Steve posted when I do piriformis (rarely). Although, you can use ultrasound with good reliability as well.
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Nah, try this technique. More reliable and safer https://www.painphysicianjournal.com/current/pdf?article=OTk0&journal=43
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I've done them under ultrasound before for slim patients. For fluoro I use a modification to Steve's technique, I come out a bit more lateral so I have a bony backstop of the pelvis (follow the diagram of the muscle out laterally).
yes, just like @pastafan above, I forgot that paper, you posted just as I was typing.
yes, just like @pastafan above, I forgot that paper, you posted just as I was typing.
i agree. i like this one better as well. advance to os, you are lateral to sciatic nerve. done
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Yep. Not unlike the other stuff pain docs do
try this technique:
with straight AP, measure distance between top of S2 and ipsilateral top of greater trochanter in centimeters, then multiply this number by 0.66. this number is the distance from the top of s2 (imaginary line between s2 and greater trochanter) and that will be your piriformis entry point
drop needle coaxial onto top of greater trochanter and this is your depth.
hold the needle at that depth and reinsert this onto the piriformis target site.
works 100% of time.
with straight AP, measure distance between top of S2 and ipsilateral top of greater trochanter in centimeters, then multiply this number by 0.66. this number is the distance from the top of s2 (imaginary line between s2 and greater trochanter) and that will be your piriformis entry point
drop needle coaxial onto top of greater trochanter and this is your depth.
hold the needle at that depth and reinsert this onto the piriformis target site.
works 100% of time.
This is how I was trained in fellowship and feel like its straight forward, however I feel like it dont always get that nice myogram picture...and im like now what
And any pain down the lateral thigh is tight it bands
TOS is a good call. Anyone who has ever been to a physical therapist now has thoracic outlet syndrome
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Did an S1 today, and I added a piriformis injection. She had a piriformis PRP injection x 4 by a competitor ($700 x 4 = $2800) and it never worked. Repeated visits to the ED recently. Clean MRI other than mild foraminal and lateral recess stenosis at L5-S1 with a Tarlov cyst at S2. Severe point tenderness deep in the glute. Negative SI provocation.
S1 TF to cover the mild foraminal and lateral recess stenosis, as well as inferior spread to bath that S2 foramen (not a believer in Tarlov cysts as pain generators 99% of the time).
As I stated above, I despise piriformis as a procedural target.
Billed a single level TFESI and I'll eat the piriformis.
1cm deep, 1cm lateral, 1cm inferior
S1 TF to cover the mild foraminal and lateral recess stenosis, as well as inferior spread to bath that S2 foramen (not a believer in Tarlov cysts as pain generators 99% of the time).
As I stated above, I despise piriformis as a procedural target.
Billed a single level TFESI and I'll eat the piriformis.
1cm deep, 1cm lateral, 1cm inferior
so, the 2 techniques referenced above have different finals targets. which one is anatomically correct? mitch has fascial/intramuscular spread, but which muscle? i always thought piriformis was more superior and lateral?
mitch looks like he is in the belly of the muscle, and the painphysician technique puts you more at the muscolotendinous junction
mitch looks like he is in the belly of the muscle, and the painphysician technique puts you more at the muscolotendinous junction
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I don't keep shooting images. I put like 4cc of injectate in there and I think if I imaged that you'd see a lot more of the muscle. What you see is like 1cc of contrast. I do think it spreads and I'd get a lot of medicine diffusely.
I also think...If this is even real...That the belly is where you need to be right?
if you acknowledge that piriformis syndrome is real, and that the radicular pain is from piriformis spasm, then the belly would be better.
if it if just glut pain and more of a tendonitis, then closer to the junction or tendon would be the target
im not sure either are all that effective TBH
This is what I get with described technique 100% of time. And you can see the orientation of muscle belly is from GT to s2. The depth that it is inserted makes it very unlikely that this is gluteus max, nor is it too transverse which would indicate the other external rotators/ abductors.
I get good relief whenever I do it for focal buttock pain reproduced with deep palpation and positive FAIR test .
I get good relief whenever I do it for focal buttock pain reproduced with deep palpation and positive FAIR test .
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Interesting, I'll have to try that.
So you drop that needle same depth as a coaxial needle to the superior tip of GT? Any idea how much deeper til os? Is it always over tip of acetabulum?
No depth deviation or c-arm tilt regardless of lordosis, butt fat, or anything else?
I've never hit os, so i'm not sure. Once did I illicit radicular pain but just pulled back.
the hardest part is pulling the needle out of the first target (the greater trochanter) without your fingers slipping or moving along the needle, which will obviously lead to incorrect placement to the piriformis target.
If needed, I oblique the c-arm to make sure the spine is midline and leave it at that angle for the entirety of the measurements between S2 and GT. I've never dealt with tilting. I've come across large buttocks folk and really frail elderly folks, but it seems to work every time.
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Thank you for the pics. My quesions is those who go for the myotendinous injection technique...do you always get that myogram 100% of the time. I feel like I hit the same target but dont always get the myogram. Then i change my depth...put more contrast in but then just end of with a mess of contrast. Anybody else have this experience?
You’re doing a soft tissue injection with fluoro, it’s bound to happen
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Just put 10 cc of 0.50% Bupiv in the injectate. If the patient has a foot drop post procedure, you hit the spot
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Maybe I’m in the minority, but I feel that piriformis syndrome is overcalled and that piriformis injections are rarely a standalone therapeutic measure.
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Yep.
Umm yeah you’re in the majority. I’m shocked that this is actually a thread amongst physicians. I probably spend too much time I will never get back telling people that they don’t have piriformis syndrome after some PT or idiot chiro convinced them that they did have it..
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I think it’s quite rare. But just like other rare things it’s nice to be ready and know the procedure when it comes up.
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Piriformis is usually compensatory for something else. So you need to figure out what that "something else" is. But in the meantime it deserves to be treated if it functionally limits the patient.
I don't enjoy getting paid for a TPI by injecting it- although you can use 77002- but there it is.
I don't enjoy getting paid for a TPI by injecting it- although you can use 77002- but there it is.
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Typically compensatory for the disc herniation compressing the nerve root a few inches cephalad?
I agree with the above. Most of these injections we get asked to do in our clinic is from a ortho surgeon who has a very high degree of Suspicion for it 🤷♂️. My question as above was more on improving the technical aspects of the injection
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i suspect very few pain physicians would do a tpi over a TFESI.
He’s an idiot..and probably just agrees with the physical therapist and has no even basic understanding of spine