RU2616122C1 - Method for treating piriformis muscle syndrome - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: first point for installation of needle for reflexotherapy is determined by building a triangle, apexes of which are: greater hip trochanter, upper posterior spine of iliac bone and ischial tuberosity. From upper posterior spine on the base of said triangle drawn is bisector, on the border of lower and middle parts of which target point is located. Needle for reflexotherapy is introduced into said point vertically until darting pains appear. After that, apparatus of vacuum-gradient therapy with cup diameter not less than 10 cm is installed above said point with needle introduced into it. Impact is realised in alternating mode for from 20 to 30 min. Course includes 5-10 procedures. Procedures are performed every second day.

EFFECT: reduction of clinical symptoms, reduction of terms and applied methods of treatment, increase of remission terms due to combined synergic impact of acupuncture into the point optimal for impact, which enhances functional activity of cells, conductivity of nerve impulses, neuromuscular transmission, improves condition of microcirculatory bed.

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Description

The invention relates to medicine, in particular to neurology, reflexology, and is intended for the treatment of patients with piriformis syndrome.

Piriformis syndrome is a pain syndrome localized in the gluteal region with possible radiation to the thigh and lower leg along the back and outer surface, to the inguinal region.

Piriformis Syndrome is the most common tunnel neuropathy. Compression of the root of L5 or S1, as well as unsuccessful injections of medicinal substances, causes pathological tension of the piriformis muscle, which leads to compression of the sciatic nerve or, with high passage, its branches, as well as the vessels accompanying it in the sub-piriform space.

The immediate causes of the primary lesion of the piriformis muscle may be:

- stretching

- trauma to the lumbosacral and gluteal regions,

- muscle overtraining,

- long stay in an antalgic pose,

- unsuccessful injection of drugs into the piriformis muscle region,

- subcooling,

- ossifying myositis.

The emergence of a secondary piriformis syndrome can be with:

- diseases of the sacroiliac joint,

- pelvic diseases, for example, with gynecological diseases.

Vertebrogenic pathology can lead to reflex muscle spasm. The piriformis syndrome (not radicular) developing according to this scheme, having muscular-tonic manifestations, is one of the most common variants of femoral and lumbar pain. With discogenic radiculopathies with damage to the spinal roots, pathological tension of the piriformis muscle in the form of a spasm is observed. In this case, there is a clinical combination of radicular and reflex mechanisms with emerging neurological manifestations of vertebral pathology.

Thus, it becomes clear that there may be vertebrogenic and non-vertebrogenic causes of piriformis syndrome.

Vertebrogenic causes:

- injuries of the spine and spinal roots,

- Tumors of the spine and spinal roots,

- radiculopathy L1 - S1 roots,

- lumbar stenosis.

Nevertebrogenic causes:

- myofascial pain syndrome,

- reflected pain arising from diseases of internal organs.

The piriformis muscle (m. Piriformis) is a flat isosceles triangle. The muscle originates from the front surface of the sacral bone, further from the axis (lateral) of the second or fourth sacral foramen (base of the triangle). The piriformis muscle is supplemented with fibers that begin in the large sciatic notch of the ilium, sometimes from the sacrospinous ligament.

The piriformis muscle begins in the area of the sacroiliac joint capsule. Further, through the large sciatic opening, its bundles exit the small pelvis, after which they pass into the short and narrow tendon, which is attached to the medial surface of the greater trochanter of the thigh. Here is the mucous bag.

The piriformis muscle does not occupy the entire sciatic foramen; it forms the upper and lower fissure. The upper gap is occupied by the superior gluteal artery and nerve. In the lower gap are the lower gluteal artery and sciatic nerve. The piriformis muscle is innervated by the branches of the sacral plexus from the spinal roots S1 and S2. Blood supply comes from the upper and lower gluteal arteries.

Functionally piriformis muscle is designed to divert the thigh and rotate it outwards. She simultaneously unbends and deflects the thigh, and also rotates it with a sharp flexor-abduction posture. This muscle is necessary for “anchoring” the femoral head by analogy with the function of the supraspinatus muscle in relation to the head of the humerus. It holds the thigh from rapid internal rotation in the first stage of running and walking. Also, with its help, an oblique force is created to the sacrum, and due to the lower part of the muscle a “shearing” force is provided for the sacroiliac joint - it pulls its side of the base of the sacrum forward and its apex back. This muscle promotes the swing (antinutations) of the sacrum. If the nutring muscles pull the sacrum forward, the piriformis muscle pulls back its lower sections towards the posterior sections of the anonymous bones.

The piriformis contracture leads to a slight stretching of its antagonists, the adductors of the thigh. However, they simultaneously rotate the thigh outwards and are in this respect a synergist of the piriformis muscle. Partially, the middle gluteus muscle rotates the thigh inward, and it also removes the thigh, not being a complete antagonist of the piriformis muscle.

Thus, in relation to the function of abduction of the thigh, all the gluteal muscles are piriformis agonists, and all adductors are antagonists. More complex muscle complexes carry out rotational movements.

The sciatic nerve trunk in 90% of cases leaves the gluteal region from the pelvic cavity under the piriformis muscle. In 10% of cases, when passing into the gluteal region, it perforates the piriformis muscle. A prerequisite for sciatic nerve compression is the piriformis muscle induction arising from its aseptic inflammation. The altered piriformis muscle is able to compress the sciatic nerve, as well as other branches of the second and fourth sacral nerves - the lower gluteal nerve, the posterior cutaneous nerve of the thigh, and the genital nerve.

Thus, when piriformis syndrome occurs, it can be:

- compression of the sciatic nerve between the sacrospinous ligament and the altered piriformis muscle,

- compression of the sciatic nerve by the altered piriformis muscle when it passes through the muscle (variant of the development of the sciatic nerve),

- compression of the branches of the second, third, fourth sacral nerves, lower gluteal nerve, posterior cutaneous nerve of the thigh, genital nerve.

The clinical picture of the piriformis syndrome is manifested by local symptoms, symptoms of compression of the sciatic nerve, symptoms of compression of the lower gluteal artery, sciatic nerve vessels.

Local symptoms include:

- pulling, aching, “braining” pain in the buttock, in the hip and sacroiliac joints, aggravated by standing, walking, bringing the thigh and squat squatting,

- in the supine position, in the sitting position with legs apart, the pain subsides a little,

- if it is good to relax the gluteus maximus muscle, under it you can feel the dense, painful when pulled pear-shaped muscle (Bonnet-Bobrovnikova symptom),

- at the point of the piriformis muscle on the back surface of the leg there is pain during percussion (Vilenkin symptom),

- soreness of the ischial spine manifests itself, on which the palpating finger stumbles when intensively sliding from the ischial tuber medially upward,

- often tonic tension of the piriformis muscle can be combined with a similar state of other muscles of the pelvic floor - the internal obstructive, coccygeal, anus levator and others, in such cases it is referred to the pelvic floor syndrome.

Piriformis syndrome is almost always accompanied by mild sphincter disorders: before starting urination, a short pause occurs.

Symptoms of compression of the sciatic nerve and blood vessels in the sub-piriform space are:

- pains during compression of the sciatic nerve have a dull, “brainy” character with a vegetative color present (sensations of stiffness, chilliness, burning sensation),

- there is an irradiation of pain throughout the leg or mainly along the innervation zone of the peroneal and tibial nerves,

- provoking factors of compression are stressful situations, change of weather, heat,

- sometimes there is a decrease in the Achilles reflex, surface sensitivity,

- if the fibers that form the tibial nerve are predominantly involved, the pain begins to localize in the posterior group of the tibial muscles: when walking, when the Laseg test; soreness is also noted in the calf and soleus muscles.

Symptoms of compression of the vessels of the sciatic nerve and lower gluteal artery are a sharp spasm of the vessels of the leg, which leads to intermittent claudication: when walking, the patient has to stop, sit down, go to bed; the skin on the leg turns pale; after rest, the patient is able to continue walking, but soon the same attack is repeated.

An important diagnostic test that confirms the leading role of the piriformis muscle in the formation of the clinical picture is the infiltration of piriformis novocaine with an assessment of the positive changes that occur.

A known method of treating patients with piriformis syndrome is to perform acupuncture by acting on standard reflexogenic points (RU 2279869 C2, 07.20.2006). However, this method does not provide an effect on various links in the pathogenesis of this syndrome.

A known method of blockade in piriformis syndrome, including the introduction of a needle through the skin into the abdomen of the piriformis muscle, stratified infiltration with anesthetic and the introduction of 10 ml of anesthetic drug into the muscle (Kogan O.G., Petrov B.G., Schmidt I.R. blockade of osteochondrosis of the spine. Kemerovo book publishing house. 1988. S. 112-114). However, this method also provides only temporary anesthesia.

In addition, during treatment with this method, a persistent cure of the syndrome is not achieved, and very often relapses occur again. Anesthetic acts briefly, is an allergenic drug, and with repeated administration can cause an inflammatory reaction.

The closest is the known method of treatment for piriformis syndrome, in which acupressure of the trigger zone is performed, followed by the introduction of an anesthetic solution into it (RU 2387440 C2, 04/27/2010). However, this method allows providing only temporary anesthesia of the zone of high pain, but does not affect other parts of the pathogenesis of this pathology.

The technical result of the claimed invention is to reduce clinical symptoms, reduce the time and methods of treatment, as well as increase the time of remission due to the combined synergistic effect of acupuncture at the most optimal point for exposure, which enhances the functional activity of the cell, due to the influence of, among other things, the conduction of the pulse along the nerve cells, neuromuscular transmission, as well as affecting the microvasculature, and vacuum gradient therapy (VGT), which itelno reinforces already begun effect on the microcirculation.

Exposure to AHT leads to a peculiar metabolic “microexplosion” of imbibed tissue elements, due to the release of inflammatory and anti-inflammatory mediators and hormones, the release of biologically active substrates (heparin, histamia, prostaglandins, cytokines). As a result, vascular tone decreases, the lumen of arterioles, precapillaries and venules widens due to stimulation of the synthesis of nitric oxide by the microvascular endothelium, the number of functioning capillaries increases, which, in turn, increases the local tissue temperature (by 3-5 ° C). In this case, loosening of adherent layers of tissues, bundles of myofibrils, elements of connective tissue — collagen and elastin fibers — loosens, viscosity decreases and, at the same time, fluidity of the gel of the main substance increases, which causes active drainage of the interstitial space.

The double, horizontal-vertical, pressure gradient that arises in the tissues changes the liquid crystal structure of the cell cytosol (thixotropic effect), activates local blood flow regulators (histamine, plasmakinins, prostaglandins, etc.), which increase the number of arteriovenous anastomoses and functionally active capillaries up to 45 times , and the volumetric blood flow velocity in them is 4-5 times. This, in turn, contributes to an increase in the difference in the gradients of hydrostatic and oncotic pressures in surface and deeper microvessels, which leads to an increase in the convection flow of liquids and metabolic processes in the microcirculation zone.

Thus, we found that these two methods (acupuncture and HRT) not only demonstrate the sum of the effects, but are in synergistic interaction with each other, enhancing the effect of each separately.

Our proposed treatment algorithm for piriformis syndrome is aimed not only at relieving pain, but also at eliminating the very reason why the disease arose. This disease should not be considered as a local manifestation of pain, but should be considered as a multicomponent and interconnected symptom complex.

The method is as follows.

The patients underwent clinical, neurological and radiological examination and general examination,

First, a point is determined by constructing a triangle, the vertices of which are the greater trochanter of the thigh, the superior posterior spine of the ilium and the ischium. A bisector is drawn from the upper back spine to the base of this triangle, at the boundary of the lower and middle parts of which the desired point is located. A needle for reflexology is vertically inserted into the obtained point until the shooting pains appear. Then, a vacuum gradient therapy apparatus with a can diameter of at least 10 cm is installed above this point with the needle inserted into it. The exposure is carried out in an alternating mode for from 20 to 30 minutes. The course of treatment is from 5 to 10 procedures. Procedures are carried out every other day.

Example 1

Patient L., 39 years old, was admitted with complaints of pain in the right gluteal region, radiating to the right leg along the lateral surface of the thigh to the knee joint. The pain intensifies with a change in body position.

From the anamnesis: Vertebroneurological history - 5 years. Regarding this exacerbation, she was treated in a clinic for 15 days: physiotherapy, drug therapy. As a result of the treatment, a slightly positive effect is noted.

Objectively: The condition is satisfactory. Sparing gait (limps on the right leg). Palpation is determined by pain at the projection point of the piriformis muscle on the right with radiation to the leg along the lateral surface of the thigh. In the course of the VB channel, marked pain is noted. Tendon reflexes live d = s. There are no sensitive violations.

R-rp. POP: osteochondrosis, L4-L5, L5-S1,1 period.

Diagnosis: Lumbar osteochondrosis L4-L5, L5-S1, 1 period, chronically recurring non-progressive course, exacerbation, stationary phase, irritative stage, piriformis syndrome on the right, 3-4 degree of clinical manifestations.

The treatment was carried out through acupuncture in combination with HBT. First, the point for installing the needle was determined by constructing a triangle, the vertices of which are the large trochanter of the thigh, the upper posterior spine of the ilium and the sciatic tubercle. A bisector is drawn from the upper back spine to the base of this triangle, at the boundary of the lower and middle parts of which the desired point is located. A needle for reflexology is vertically inserted into the obtained point until the shooting pains appear. Then, a vacuum gradient therapy apparatus with a can diameter of at least 10 cm is installed above this point with the needle inserted into it. The exposure was carried out in an alternating mode for 20 minutes. The course of treatment was 8 procedures. The procedures were performed every other day.

After the course of treatment, the pain syndrome was almost completely stopped. Palpatory mild soreness, along the VB channel there is no pain.

During follow-up observation for 3 years, the manifestation of osteochondrosis was observed once after severe physical exertion, for a short time (1-2 days).

Example 2

Patient S., 44 years old, was admitted with complaints of pain in the left gluteal region, radiating to the left leg along the lateral surface of the leg to the calcaneus. Periodically, signs of hyposthesia in the lower leg and foot.

From the anamnesis: Vertebroneurological history - 12 years. This exacerbation for three months. It was treated: drug therapy, physiotherapy, acupuncture. As a result of the treatment, a slight improvement is noted.

Objectively: The condition is satisfactory. Smoothed lumbar lordosis. Dull pain is palpated at the point of the piriformis muscle on the left with irradiation in the leg to the popliteal region, along the VB channel. Tendon reflexes live d = s. Signs of hyposthesia along the L5 root.

R-rp. POP: osteochondrosis, L3-L4, L5-S1, 2 period.

Diagnosis: Lumbar osteochondrosis L3-L4, L5-S1, period 2, chronically recurring non-progressive course, deficiency stage, piriformis syndrome on the left, 3 degree of clinical manifestations.

The treatment was carried out through acupuncture in combination with HBT. First, the point for installing the needle was determined by constructing a triangle, the vertices of which are the large trochanter of the thigh, the upper posterior spine of the ilium and the sciatic tubercle. A bisector is drawn from the upper back spine to the base of this triangle, at the boundary of the lower and middle parts of which the desired point is located. A needle for reflexology is vertically inserted into the obtained point until the shooting pains appear. Then, a vacuum gradient therapy apparatus with a can diameter of at least 10 cm is installed above this point with the needle inserted into it. The exposure was carried out in an alternating mode for 30 minutes. The course of treatment was 10 procedures. The procedures were performed every other day.

After the course of treatment, the pain syndrome was almost completely stopped. Palpatory mild soreness at the piriformis, along the VB channel, the pain stopped. Sensitivity was restored along the L5 root.

During follow-up observation for three years, the manifestation of osteochondrosis was observed once after severe physical exertion. Shortly 2-3 days.

Example 3

Patient R., 35 years old, was admitted with complaints of pain in the right gluteal region, radiating to the right leg along the lateral surface of the thigh to the knee joint. The pain intensifies with a change of position.

From the anamnesis: Vertebroneurological history of 6 years. Regarding this exacerbation, he was treated in a clinic for 12 days: physiotherapy, drug therapy. As a result of the treatment, a slightly positive effect is noted.

Objectively: the condition is satisfactory. A gentle gait (limps on the right leg), pain is palpated at the point of projection of the piriformis muscle from the right with irradiation into the leg along the lateral surface of the thigh. A muscle tensile test was also performed: a patient lying on his back is invited to relax the muscles if possible. In order to distract the patient’s attention, a light back flexion-extension of the foot of the test leg is performed. Then the doctor bends the patient’s leg in the knee and hip joints with one hand, putting pressure on the knee (along the axis of the vertically placed thigh), with the other hand rotates and brings the thigh inward.

If at the same time pain appears in the region of the greater trochanter at the site of attachment of the piriformis muscle and buttock, the symptom is considered positive. When conducting this test, the patient is positive. Tendon reflexes d-s, no sensitive disturbances.

R-rp. POP: osteochondrosis, L4-L5, L5-S1, 1 period.

Diagnosis: lumbar osteochondrosis L4-L5, L5-S1, period 1, chronic recurrent non-progressive course, exacerbation, stationary phase, irritative stage, piriformis syndrome on the right, 3-4 degree of clinical manifestations.

The treatment was carried out through acupuncture in combination with HBT. First, the point for installing the needle was determined by constructing a triangle, the vertices of which are the large trochanter of the thigh, the upper posterior spine of the ilium and the sciatic tubercle. A bisector is drawn from the upper back spine to the base of this triangle, at the boundary of the lower and middle parts of which the desired point is located. A needle for reflexology is vertically inserted into the obtained point until the shooting pains appear. Then, a vacuum gradient therapy apparatus with a can diameter of at least 10 cm is installed over this point with the needle inserted into it. The exposure was carried out in an alternating mode for 25 minutes. The course of treatment was 5 procedures. The procedures were performed every other day.

After the course of treatment, the pain syndrome was almost completely stopped. Palpatory mild soreness along the VB channel, no pain. During the test, the piriformis tensile pain stopped.

According to follow-up observations for 3 years, the manifestation of osteochondrosis was observed once after severe physical exertion, for a short time (1-2 days).

The proposed method of treatment was applied to 43 patients suffering from piriformis syndrome. Among the examined patients, 30% of patients with a mild disease severity with moderate pain syndrome were identified, 54% recorded a moderate severity of the disease with severe pain, 16% with a severe disease with a pronounced pain syndrome.

All patients showed a positive dynamics of clinical syndromes in the form of a decrease in pain and muscle-tonic syndromes, an increase in the range of motion, restoration of sensory and motor disorders, as well as an improvement in the quality of life of the patient as a whole.

As a result of the treatment, pathological symptoms in the study of neurological status regressed by 50% by the middle of the course, with a complete regression of symptoms in 85% of patients by the end of the course of treatment.

A comprehensive assessment of the treatment results allowed us to establish a significantly higher significant improvement in the group of patients with piriformis muscle syndrome receiving the combined effects of acupuncture and IHT (85%) than in the comparison group (53%), p <0.01.

Thus, on the basis of the conducted studies, the feasibility of using the combined effects of acupuncture and HRT when choosing the most optimal point for exposure, due to the synergistic effect of acupuncture, which enhances the functional activity of the cell due to the influence, including on the conduction of the pulse through nerve cells, neuromuscular transmission, is scientifically substantiated. as well as acting on the microvasculature, and vacuum gradient therapy (VGT), which significantly It eliminates the effect that has already begun on the microvasculature.

Claims (1)

A method of treating piriformis syndrome, characterized in that the reflexology needle is first set to a point that is determined by constructing a triangle, the vertices of which are the greater trochanter of the thigh, the superior posterior iliac spine and sciatic tubercle, conduct a bisector from the superior posterior spine to the base of this triangle , at the border of the lower and middle parts of which the desired point is located, a needle is vertically inserted into the obtained point until shooting pains appear; then a vacuum gradient therapy apparatus with a jar diameter of at least 10 cm is installed over this point with the needle inserted into it and the exposure is performed in an alternating mode for 20 to 30 minutes, the course of treatment is 5 to 10 procedures, every other day.