1. 2008;11;327-331Confirmation of Needle Placement Within the Piriformis Muscle of a Cadaveric Specimen Using Anatomic Landmarks and Fluoroscopic Guidance
   Cadaveric Study
   Michelle Pepper, MD, William Sullivan, MD, Peter Gonzalez, MD, and Venu Akuthota, MD.

Of patients presenting to pain clinics, complaints are of low back or buttock pain with or without radicular leg symptoms is one of the most common. Piriformis syndrome may be a contributor in up to 8% of these patients. The mainstay of treatment is conservative management with physical therapy, anti-inflammatory medications, muscle relaxants, and correction of biomechanical abnormalities. However, in recalcitrant cases, a piriformis injection of anesthetic and/or corticosteroids may be considered. Because of its small size, proximity to neurovascular structures, and deep location, the piriformis muscle is often injected with the use of commuted tomography (CT), magnetic resonance imaging (MRI), ultrasound (US), fluoroscopy, electrical stimulators, or electromyography (EMG). Numerous techniques have been proposed using one or a combination of the above modalities. However, application of these techniques is limited by unavailability of CT, MRI, and EMG equipment as well as a paucity of trained physicians in US-guided procedures in many pain treatment centers throughout the United States. Fluoroscopy, however, is more widely available in this setting.

This study utilized a cadaveric specimen to confirm proper needle placement for piriformis or peri-sciatic injection utilizing the previously documented landmarks for fluoroscopic guidance as described by Betts. An anteroposterior of the pelvis with inclusion of the acetabular region of the hip and the inferior aspect of the sacroiliac joint was obtained. The most superior-lateral aspect of the acetabulum and the inferior aspect of the sacroiliac joint were identified. A marker was placed one-third of the distance from the acetabular location to the inferior sacroiliac joint, indicating the target location. A 22-gauge, 3.5-inch spinal needle was directed through the gluteal muscles to the target location using intermittent fluoroscopic guidance. The posterior ileum was contacted and the needle was withdrawn 1 –2 mm. This approach found the needle within the piriformis muscle belly 2 –3 cm lateral to sciatic nerve. The present study was the first study, to our knowledge, that has confirmed the intramuscular position of the needle within the piriformis muscle of a cadaveric specimen using these anatomic landmarks and fluoroscopic guidance.