PIRIFORMIS MUSCLE SYNDROME: ETIOLOGY, PATHOGENESIS, CLINICAL MANIFESTATIONS, DIAGNOSIS, DIFFERENTIAL DIAGNOSIS AND THERAPY
Autori:
Vjekoslav Grgić
Sažetak
Termin piriformisni sindrom (PS), koji je uveo Robinson 1947. godine, označava skup znakova i simptoma uzrokovanih poremećajima mišića piriformisa (MP). Budući da poremećaji MP-a dovode do iritacije/kompresije anatomskih struktura koje prolaze ispod njegova trbuha, glavni klinički znakovi i simptomi PS-a zapravo su klinički znakovi i simptomi iritacije/kompresije živčanih i vaskularnih struktura koje prolaze kroz foramen infrapiriforme: ishijadični živac/IŽ, n. gluteus inferior, n. cutaneus femoris posterior, n. pudendus, a. i v. glutea inferior te a. i v. pudenda interna. U kliničkoj slici obično dominiraju znakovi i simptomi iritacije/kompresije IŽ-a (iritacija IŽ-a®bol u križima i stražnjici, ishialgija, parestezije u distribuciji IŽ-a; kompresija IŽ-a®bol u križima i stražnjici, ishialgija, parestezije i neurološki deficit u distribuciji IŽ-a). Iritacija/kompresija drugih struktura može rezultirati ovim znakovima i simptomima: n. gluteus inferior®atrofija glutealnih mišića; n. cutaneus femoris posterior®bol, parestezije i smetnje osjeta u stražnjem dijelu bedra; n. pudendus® pudendalna neuralgija, bol tijekom seksualnog odnosa (dispareunija), seksualna disfunkcija, teškoće s mokrenjem i stolicom; a. glutea inferior®ishemijska bol u stražnjici; a. pudenda interna®ishemijska bol u području vanjskih spolnih organa, međice i rektuma, seksualna disfunkcija, teškoće s mokrenjem i stolicom; v. glutea inferior®venska staza u glutealnom području; v. pudenda interna®venska staza u području vanjskih spolnih organa i rektuma. Funkcijski/neorganski i organski poremećaji MP-a mogu uzrokovati PS: spazam, skraćenje, hipertrofija, anatomske varijacije, edem, fibroza, adhezije, hematom, atrofija, cista, burzitis, apsces, miozitis osifikans, endometrioza, tumori (funkcijski poremećaji: spazam i skraćenje MP-a). Najčešći uzroci PS-a su spazam, skraćenje i hipertrofija MP-a te anatomske varijacije MP-a i IŽ-a. U 5–6% bolesnika s križoboljom i/ili unilateralnom ishialgijom uzrok boli su poremećaji MP-a. Dijagnoza PS-a može se postaviti na temelju anamneze, kliničke slike, kliničkog pregleda, EMNG-a, periishijadične anestetičke blokade MP-a i radioloških pretraga (MR zdjelice/MP-a; MR neurografija LS pleksusa i IŽ-a). Terapija PS-a uključuje medikamentnu terapiju, modifikaciju aktivnosti, fizikalnu terapiju, kineziterapiju, akupunkturu, terapijske periishijadične blokade, injekcije botulinskog toksina i kirurški tretman (tenotomija MP-a, neuroliza IŽ-a).
Summary
The term ’piriformis syndrome’ (PS), introduced by Robinson in 1947, implies a group of signs and symptoms caused by piriformis muscle (PM) disorders. Since PM disorders lead to irritation/compression of the anatomic structures passing under its belly, the main clinical PS signs and symptoms are actually the clinical signs and symptoms of irritation/compression of neural and vascular structures passing through the infrapiriform foramen: sciatic nerve/SN, inferior gluteal nerve, posterior femoral cutaneous nerve, pudendal nerve, inferior gluteal artery and vein and inferior pudendal artery and vein. The clinical picture is usually dominated by signs and symptoms of irritation/compression of SN (SN irritation®low back and buttock pain, sciatica,paresthesias in distribution of SN; SN compression®low back and buttock pain,sciatica, paresthesias and neurologic deficit in distribution of SN). Irritation/compression of other structures can result in the following signs and symptoms: inferior gluteal nerve®atrophy of gluteal muscles; posterior femoral cutaneous nerve®pain, paresthesias and sensory disturbances in the posterior thigh; pudendal nerve®pudendal neuralgia, painful sexual intercourse (dyspareunia), sexual dysfunction, urination and defecation problems; inferior gluteal artery®ischemic buttock pain; inferior pudendal artery®ischemic pain in the area of external sex organs, perineum and rectum, sexual dysfunction, urination and defecation problems; inferior gluteal vein®venous stasis in gluteal area; inferior pudendal vein®venous stasis in external sex organs and rectum. Functional/ non-organic and organic PM disorders can cause PS: spasm, shortening, hypertrophy, anatomic variations, edema, fibrosis, adhesions, hematoma, atrophy, cyst, bursitis, abscess, myositis ossificans, endometriosis, tumors (functional disorders: PM spasm and shortening). The most common causes for PS are PM spasm, shortening and hypertrophy and anatomic variations of PM and SN. In 5–6% of patients with low back pain and/or unilateral sciatica, the pain is caused by PM disorders. PS diagnosis can be made on the basis of anamnesis, clinical picture, clinical examination, EMNG, perisciatic anesthetic block of PM and radiological exams (pelvis/PM MRI; MR neurography of LS plexus and SN). PS therapy includes medicamentous therapy, physical therapy, kynesitherapy, acupuncture, therapeutic perisciatic blocks, botulinum toxin injections and surgical treatment (tenotomy of PM, neurolysis of SN).
