Pyriformis Synd./ Meralgia P./ Miscellaneous

PIRIFORMIS SYNDROME & MERALGIA PARESTHETICA( NUMBNESS IN OUTER THIGH)

Piriformis syndrome is a painful condition of the hip in which the piriformis muscle, located in the buttock, goes in to  spasm and causes buttock pain. The piriformis muscle can also cause irritation to the Sciatic nerve and result in pain, numbness and tingling along the back of the leg and foot (similar to sciatica). The piriformis muscles are engaged in daily activities and enable the internal rotation movement of thighs. Symptoms associated with the condition include pain, numbness and tingling in the buttocks, tenderness of the muscles with pain and difficulty in sitting comfortably.

The common causes of piriformis syndrome are: the overuse of piriformis muscle, Sacroilitis and prolonged sitting which may apply excess pressure over the muscles and nerves causing numbness and pain in the buttocks and thighs.

Conventional treatment method involves taking rest, NSAIDS/ anti-inflammatory drugs, avoiding activities that trigger the symptoms, alternate ice and heat packs on the buttocks or legs and physical therapy that improve the strength and flexibility of the muscles.

Alternative treatment methods at Beth Yehuwdah Arthritis Centre, Pullad and Daystar clinic, Alappuzha for Pyriformis Syndrome:

1) Platelet Rich Plasma (PRP) in Pyriformis Syndrome :

PRP is given when the Pyriformis Syndrome is due to underlying inflammation in the Sacroiliac region. Plasma rich platelet prolotherapy is the recent trend in treating various joint conditions and is designed to stimulate repair of chronically inflamed tissues in the affected Sacroiliac joint and to reduce swelling and pain caused by the condition, indirectly improving symptoms of Pyriformis Syndrome. PRP prolotherapy is a combination treatment where PRP is injected into the joint and dextrose prolotherapy is given to the ligaments and muscle attachments surrounding the joint. This treatment may help a patient who does not want surgery and helps to overcome the disease condition with minimally invasive injection techniques. The treatment method stimulates the natural immune repair mechanisms of the body and delivers the building block essential to build and repair damaged tissues.

How does PRP work?

Blood components are of four major types - plasma, platelets, white blood cells and red blood cells. Platelets assist in clotting and are also the “first-responders” of the body post injury; helping repair an injured region and in building up of new tissue and thereby promoting the healing process. Once platelets contact collagen in damaged tissues, the platelets release various biological growth factors (Table 1 as given below) to promote healing in soft tissues locally. Activated platelets commonly release the following growth factors:

Table 1: Various biological growth factors released by PRP when activated

PRP injection delivers a high concentration of autologous (patient’s own) platelets to the Sacroiliac region (related to Pyriformis) . Platelets present in the blood are the first responders to an injured area and helps build up new soft tissues. Introducing high concentration of platelets directly into the site using PRP injection stimulates the healing process and faster recovery from the condition.

Patient Benefits of PRP Prolotherapy

• Minimally invasive treatment method
• Almost painless injection technique using very thin needles under local anesthesia
• Significantly reduces the symptoms associated with Sacroilitis, secondarily reduces symptoms of Pyriformis Syndrome.
• Reduced risk of adverse events
• Assists in repair and tightening of ligaments in the sacroiliac region, improving joint stability and ease of walking
• Safe and effective treatment method
• Assists healing and recovery
• PRP Prolotherapy usually results in safe, significant, improvement of hip pain, function and reduction of stiffness.

Neural & Soft Tissue Infilteration Therapy (NESTIT)

Low Dose Steroid Infilteration/ Neural & Soft Tissue Infilteration Therapy (NESTIT):  Steroid tablets and injections of the group Corticosteroids, (which are very different from Anabolic steroids misused by some athletes) have been repeatedly proven medically for the last 70 years in the successful treatment of inflammatory conditions due to its potent anti-inflammatory effect. Though corticosteroids are very effective in reducing inflammation, they carry numerous potential side effects, which are undesirable. To circumvent this problem, and in order to utilize the potent anti-inflammatory effects of steroid injections, at the same time taking appropriate measures to considerably lower its side-effects, Dr Tejaz Koshy John in 2010 while working as an Orthopaedician in his private clinic in Guyana, South America developed NESTIT. NESTIT stands for (Juxta) Neural and Soft Tissue Infilteration Therapy. It consists of injecting small amounts of diluted anti inflammatory steroid solution indirectly near (juxta) nerve CCPs- (chronic constricting points) in the lower back/ hip/ neck/ shoulder regions, in order to reduce juxtaneural and perineural inflammation, as well as in certain soft tissue sites including but not limited to trigger points (painful muscle “knots”)/ myofascial syndrome and/or enthesitis (inflammation of soft tissue-bone junctions) and/or sites of nerve inflammation (neuritis/ radiculitis) and/or bursitis (inflammation of fluid filled cushions called bursa) and/or additional sites causing pain referrals (referred pain) to distant sites; in order to obtain a reduction in inflammation and pain in the concerned joint/ region/ limb. It is preferably given for those patients who have Rheumatoid Arthritis, Inflammatory Arthritis, Synovitis, Inflammatory Low Back Pain, Spondyloarthropathy & Nerve and Nerve root irritation. It is not a substitute for DMARDS (Disease modifying anti rheumatoid drugs), however when given with low dose DMARDS, in Dr Tejaz John’s clinical experience it may result in significant reduction of local inflammation, pain and improvement of joint function in most cases, also indirectly reducing side effects of high dose DMARDS.

NESTIT involves 

1. Administeration of low dose local steroid via infilterative type of injection technique rather than giving oral steroids (as cumulative daily dosage of oral steroids over a 6 week period could exceed the dose of local steroid injection by almost 5 to 10 times) or conventional single injection into joints directly.
2. Reduce the dosage of Steroid given via injection and the use of a sliding scale according to patient’s body weight and height to regulate dosage. A 40 kg woman of 4 feet 9 inches should not receive the same dosage as a 100 kg male of 6 feet height.
3. Dilute the low dose steroid injection upto 80% with sterile water and local anesthetic.
4. Administer relatively insoluble low dose steroid via multiple infilterations locally in inflamed tissues in very small amounts indirectly near (juxta) nerve CCPs- (chronic constricting points) in the lower back/ hip/ neck/ shoulder regions as per requirement, in order to reduce juxtaneural and perineural inflammation, as well as in certain soft tissue sites including but not limited to trigger points (painful muscle “knots”)/ myofascial syndrome and/or enthesitis (inflammation of soft tissue-bone junctions) and/or sites of nerve inflammation (neuritis/ radiculitis) and/or bursitis (inflammation of fluid filled cushions called bursa) and/or additional sites causing pain referrals (referred pain) to distant sites; in order to obtain a reduction in inflammation and pain in the concerned joint/ region/ limb.
5. Identification of high risk patients and risk stratification to reduce possibility of side effects, for eg. Patients suffering from serious heart & liver conditions tuberculosis, infections, significant osteoporosis, immuno-compromised patients, menstrual irregularities, already having Cushing’s syndrome, ongoing significant hair loss etc.
6. Regular monitoring of body weight and physical appearance for early detection of Cushingoid features, if it occurs (rarely), to delay/ avoid further injections.
7. Control of High Blood Pressure and Diabetes prior to giving injections.
8. Doing skin sensitivity tests to rule out allergic reactions to the drugs.
9. Explaining possibilities of common & rare side effects to the patient and taking precautions regarding other common side effects wherever possible.
10. Opting for/ Shifting to regenerative treatments like Platelet Rich Plasma and Dextrose Prolotherapy wherever there is secondary degenerative disease / soft tissue damage, once the severe inflammation subsides.

In Dr Tejaz John’s clinical experience, the patient benefits of Low Dose Steroid Infilteration/ Neural & Soft Tissue Infilteration Therapy (NESTIT) treatment are:

• Minimally invasive treatment method
• Almost painless injection technique using very thin needles under local anesthesia
• Significantly reduces the symptoms associated with Inflammation in cases of Arthritis/ Sacroilitis/ Enthesitis/ nerve irritation associated with Pyriformis Syndrome.
• Reduced risk of adverse events compared to oral steroid tablets which are taken daily, due lower dosage (very low steroid dosage compared to cumulative oral steroids over 6 week period).
• Reduced risk of side effects/ adverse effects due to prior risk stratification and identification of high risk patients vs. low risk patients by doing precautionary steps and tests prior to giving injection.
• Reduced incidence of post-injection pain due to highly diluted steroid solution.
• Reduces joint stiffness.
• More effective treatment method in inflammatory conditions.
• Faster recovery.
• NESTIT treatment results in significant, effective, progressive improvement of pain and function if given in series.

MERALGIA PARESTHETICA is a condition caused due to irritation or compression of nerves of the outer thigh under the pelvis bone protuberance called ASIS (Anterior Superior Iliac Spine) causing tingling, numbness and burning pain in the outer thigh region. Numerous factors can account to the cause of the condition including tight clothing, obesity, local trauma as the nerves may become compressed, or pinched.

Clinical examinations are conducted to evaluate the symptoms along with strength and sensory perseption of the affected thigh. Conventional treatment focuses on relieving nerve compression through pain relievers, medications and surgery to decompress the nerve with severe and long-lasting symptoms.

Alternative treatment method at Beth Yehuwdah Arthritis Centre, Pullad and Daystar clinic, Alappuzha for Meralgia Paresthetica:

NESTIT (Neural and Soft Tissue Infilteration Therapy): NESTIT could be a great option to treat Meralgia Paresthetica. It is a unique and innovative Injection based treatment originally developed by Dr Tejaz John in 2010 in Guyana, South America . He has used it extensively for the past 8.5 years. It generally consists of injecting small amounts of diluted anti inflammatory steroid solution indirectly near nerve CCPs (chronic constricting points) as well as in certain soft tissue sites in the pelvis and hip region which are in close proximity to sites of nerve inflammation (neuritis/ radiculitis) in order to obtain a reduction/ cessation in symptoms of Meralgia Paresthetica.

In Dr Tejaz John’s clinical experience, the patient benefits of NESTIT treatment are:

• Minimally invasive treatment method
• Almost painless injection technique using very thin needles under local anesthesia
• Significantly reduces the symptoms associated with nerve irritation in case of Meralgia Paresthetica in most patients.
• Reduced risk of adverse events compared to oral steroid tablets which are taken daily, due lower dosage (very low steroid dosage compared to cumulative oral steroids over 6 week period).
• Reduced risk of side effects/ adverse effects due to prior risk stratification and identification of high risk patients vs. low risk patients by doing precautionary steps and tests prior to giving injection.
• Reduced incidence of post-injection pain due to highly diluted steroid solution.
• More effective treatment method in inflammatory conditions.
• Faster recovery.
• NESTIT treatment usually results in significant, effective, progressive improvement of pain and function if given in series.
  
  At Beth Yehuwdah Arthritis Centre, Pullad and Daystar Clinic, Alappuzha we provide minimally invasive treatment options for patients suffering from Piriformis syndrome/ Meralgia paresthetica condition. To know more about treatment options and treatment costs, book an appointment now.