Endoscopic piriformis tenotomy and sciatic nerve release: Why and how?

Background: Piriformis syndrome, historically defined as sciatic nerve compression by the piriformis muscle, is increasingly recognized as a subset of deep gluteal syndrome often involving fibrovascular adhesions rather than simple compression. Despite its prevalence, the condition remains a diagnostic challenge due to overlapping clinical presentations with spinal and intra-articular hip pathologies.

Objective: This article aims to define the clinical indications for surgical intervention, describe the technical execution of endoscopic sciatic nerve release and piriformis tenotomy, and evaluate postoperative functional outcomes.

Key Points: Diagnosis requires the exclusion of lumbar spine disease, ischiofemoral impingement, and intra-articular hip degeneration. Clinical assessment utilizes provocative maneuvers, including passive traction in hip flexion and active abduction-external rotation tests. Magnetic resonance imaging and ultrasound-guided perineural injections provide essential diagnostic confirmation. Surgical intervention is indicated only after six months of failed conservative management, including specialized physiotherapy and injections. The endoscopic approach, performed in the prone or lateral position, allows for comprehensive decompression of the deep subgluteal space from the greater sciatic notch to the ischium. Technical steps involve trochanteric bursectomy, identification of the triceps coxae, and meticulous neurolysis of fibrovascular bands. Reported outcomes show a 77.8% success rate with significant functional improvement, though patient selection remains the primary determinant of surgical success.

Conclusion: Endoscopic sciatic nerve release and piriformis tenotomy offer a reproducible and effective treatment for refractory deep gluteal syndrome. Success depends on rigorous diagnostic exclusion and precise arthroscopic neurolysis to restore nerve mobility throughout the subgluteal space.