How do you differentiate between Sciatica caused by Piriformis syndrome and Spinal herniation?

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My doctor had me take a CT scan and he confirmed I have Spinal protrusion on level L3-L5, L4–5 and Spinal herniation at L5-S1.

Took pain meds and traction for 4 weeks and saw no improvement. Went to a physiotherapist for Dynamic traction and IFT. He then re-examined me and conclued that I have Piriformis syndrome and not spinal herniation. The reason that he gave was that I was able to rise my leg more than 40 degrees in my SLR test.

After seeing my pelvic CT he stated that having disc prolapse/protrusion on a CT doesn't confirm that the sciatic nerve is being impinged due to the herniation and that I have Piriformis syndrome. So inorder to confirm this he asked me to take an weight bearing x-ray. Is there a way to confirm Piriformis syndrome or exclude it?

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  • Posted

    They usually diagnose piriformis syndrome by physical examination. Yes, if you had no nerve root pain (spinal) when you did the SLR your is unlikely to be coming from the spine.
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    • Posted

      Thanks alot for the reply melissa91009

      The thing is I did have a pain during my SLR both times, only thing was the angle of movement that I had, it was above 40 degrees with the physiotherapist. And I have sciatica when I do my day to day chores.

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  • Posted

    *your pain (sorry). Did the dr examine your leg reflexes? That can help rule in or out a spinal problem causing the symptoms.
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    • Posted

      Yep, he checked both the deep tendon reflex and also did some neurological exams, all were normal except for my SLR. This was done by the physician who first diagnosed me as spinal herniation. Even after seeing that they were normal he said that I had spinal herniation but a milder version of it. The physiotherapist did the same and diagnosed as piriformis syndrome.
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  • Posted

    The sciatic nerve is a convergence of 4 spinal nerve roots from L4, L5, S1 and S2. If you have sciatic nerve pain from spinal nerve root irritation then ususally you would have pain on palpation at the base of the spine even if you were experiencing no LBP.  >40 degrees SLR won't necessary rule out nerve root irritation. Leg drop test would be better option but still not specific enough. Once the nerve is irritated it can be really hard to say whether it is coming from nerve root or compression in the gluteal area. Usually piriformis symdrome will respond well to soft tissue release and stretching.

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    • Posted

      Thanks for the answer thesprc, doing stretches and exercises for piriformis syndrome with an unconfirmed diagnosis would'nt that make the spinal herniation worse? What I really wanna know is can piriformis syndrome be ruled out our confirmed by using a x-ray?

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    • Posted

      In terms of exercises it would depend on which ones you do and how vigourously you do them. Even if there is nerve root irritation causing the sciatic symptoms it is important to do gentle graded exercise if you are able. In terms of X-Ray diagnosing priformis syndrome that is unlikely. This deep gluteal area is soft tissue and the best imaging technique would be MRI. Very rarely can imaging alone diagnose an issue. It generally needs to be used in combination with good history taking and physical assessment. If you suspect it is piriformis syndrome then someone who has expertise in deep gluteal syndrome (DGS) would be useful. What we call piriformis syndrome is one aspect of what is now being termed DGS.
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  • Posted

    Hi,

    Yes this can be checked through physical examination my osteopath checked for me. He pressed on distinct spots on my back and bottom in order to check. The muscles will go into spasm due to disc damage but he can release these fairly easily with deep massage, you can do it yourself with a tennis ball. I still had bad sciatica even when the muscles had been worked on and the only thing that relieves it is traction on the L5/S1 disc which completely removes the pain in my foor until the Osteo lets go. This is how I was sure it was an issue with my back and not muscular. I cannot raise my leg at all in the straight leg test and when someone else does it I get pain in my back below 20 degrees. Can you get an MRI scan?

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    • Posted

      Thanks for the reply helen10458

      An MRI yea, but my physiotherapist said that an dl and sl spinal xray (anterioposterior and lateral views) are enough to in my case and I seriously have doubts about wheather an xray is enough to confirm my diagnosis.

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