Endoscopic Piriformis Release

What is Piriformis Tendon Release?

Piriformis tendon release is a surgical procedure that involves the excision or cutting of the piriformis tendon in the hip to reduce pain and improve range of motion. It is performed in a hospital or a private clinic, either via open surgery or through a minimally invasive endoscopic approach. The endoscope is a long, thin, flexible tube with a tiny video camera and light at its end.

Compared to the open surgery option, the endoscopic release has been shown to possess fewer complications and have a higher success rate, with lower recurrence and less scarring and postoperative pain.

What are the Indications for Piriformis Tendon Release?

Piriformis tendon release is considered when non-surgical approaches such as heat and ice packs, medications, physical therapy, and corticosteroid or anesthetic injections have been unsuccessful in reducing your hip pain for a period of 6 to 12 months.

Piriformis tendon release is recommended for the treatment of chronic pain in the lower back, gluteal region, or the posterolateral hip, due to a rare condition called Piriformis syndrome. 

What is Piriformis Syndrome?

Piriformis syndrome is the pain, tingling, and numbness felt in your hip joint due to compression of the sciatic nerve by the surrounding muscles and tendons, including the piriformis, a small muscle located deep in the buttock. The symptoms may radiate to your legs based on the severity of nerve compression. Pain may be exacerbated by activities that put pressure on the piriformis muscle such as prolonged sitting, running, or climbing stairs.

Pre-Surgical Preparation for Piriformis Tendon Release

Before scheduling piriformis tendon release surgery, your surgeon explores your overall health status, medical history, and lab reports. 

• You may be required to undergo a few diagnostic tests as deemed suitable by your surgeon.
• You are given specific instructions related to diet, medications, and lifestyle that you must follow up to your surgery for the best outcome. 
• Certain foods may be restricted until your surgery. 
• To ensure a successful surgery, you are advised to quit smoking and perform regular exercise. 
• Avoid consumption of solids or liquids at least 8 hours prior to surgery.
• You should arrange for someone to drive you home after the surgery.
• You are required to change into a hospital gown or surgical drape prior to the procedure.

Piriformis Tendon Release Procedure

The general steps for piriformis tendon release, either via an open or endoscopic approach, are as follows:

• You are placed on the operating table on your side and administered anesthesia. Your doctor may use general or local anesthesia based upon your condition.
• The incision site is identified and marked.

Open Piriformis Tendon Release

In this technique, your surgeon makes a single long incision in your skin along the side of your hip to access the hip joint. 

• The incision is continued into the deeper fat layers of the hip joint to isolate the gluteus maximus muscle which is dissected and split to reach the greater trochanter of the femur (thigh bone).
• At this stage, retractors are introduced to allow better visibility of the underlying structures.
• The piriformis tendon is identified and cut (transected) using electrocautery (cauterization using a heated needle or instrument), and allowed to retract. This step is called piriformis tendon release. 
• The hip’s range of motion is checked at this stage by moving your leg in various directions to check for signs of trochanteric impingement. If necessary, a small amount of bone can be resected (cut and removed) from the greater trochanter.
• The sciatic nerve is then identified and checked for any further compression. Any unwanted adhesions or fibrovascular bands which cause pressure are resected via electrocautery using a radiofrequency ablation device and a shaver.
• A final range of motion of the hip joint is assessed to ensure there is no further impingement or sciatic nerve compression.
• The wound is irrigated with saline solution to remove the loose cellular debris from the wound.
• The surgical incision is closed, sutured, and dressed.

Endoscopic Piriformis Tendon Release

In an endoscopic piriformis tendon release, one or more small incisions known as a portal are made in the side of your hip joint. 

• Your surgeon identifies the greater trochanter of your thigh bone and the posterolateral and accessory lateral portals are marked and created.
• The posterolateral portal is utilized for inserting the endoscopic camera, and the accessory lateral portals are utilized for electrocautery and miniature instruments.
• Based on the images generated by the endoscope, the trochanteric bursa is located and a bursectomy is carried out via the accessory portal to expose the piriformis tendon.
• Then, the piriformis tendon is identified and isolated using electrocautery to access the sciatic nerve. 
• The sciatic nerve is then located near the piriformis and portions of the sciatic nerve are removed using electrocautery.
• The thighbone may also be reshaped based on the extent of damage. 
• Your leg is moved in various directions to check for a satisfactory range of motion.
• Once the sciatic nerve is completely isolated, complete piriformis muscle release is performed using electrocautery, releasing the entrapped sciatic nerve.
• Once again, your leg is moved in various directions to check for a satisfactory range of motion.
• Finally, the surgical instruments are removed.
• The surgical incisions are closed in layers and a sterile, waterproof dressing is applied.

Post-surgical Care for Piriformis Tendon Release

Following surgery, you will be monitored for recovery and any side effects. Intravenous antibiotics may be administered, and your vitals will be checked. You may be required to stay in the hospital for 1 to 2 days, or longer depending on your condition.

Some of the common post-operative care instructions include:

• You may notice pain and discomfort in the hip area. Medications will be provided for comfort.
• Medications may also be prescribed as needed for adverse effects of the anesthesia, such as vomiting and nausea.
• You are encouraged to walk after your surgery to prevent blood clots. Use assistive devices such as crutches until normal gait and muscle function are achieved.
• Keep the surgical site clean and dry. Instructions on surgical site care and bathing will be provided.
• Eating a healthy diet rich in vitamin D is strongly advised to promote healing and a faster recovery.
• Refrain from strenuous activities or lifting heavy objects for the first couple of months. A gradual increase of activities over a period of time is recommended.
• An individualized physical therapy regimen is designed to strengthen the piriformis and gluteal muscles and optimize pelvic alignment and hip function.
• You will be able to return to your normal activities in a couple of months; however, return to sports may take 4 to 6 months.

A follow-up appointment will be scheduled to monitor your progress.

What are the Risks and Complications of Piriformis Tendon Release? 

Some of the risks and complications of piriformis tendon release may include:

• Anesthetic side-effects such as nausea and vomiting
• Formation of blood clots
• Infection
• Injury to surrounding soft-tissue structures