Comparison of Pulsed Radiofrequency and Endoscopic Piriformis Release for Refractory Piriformis Syndrome: A Propensity Score-Matched Retrospective Cohort Study.

Piriformis syndrome (PS) causes sciatic nerve entrapment and chronic pain. In refractory cases, pulsed radiofrequency (PRF) and endoscopic piriformis release (EPR) are used, but comparative evidence is limited. This retrospective cohort study compared PRF and EPR in patients treated from 2018 to 2024 at a tertiary hospital using propensity score matching (PSM). Patients with PS, unresponsive to conservative treatment (≥3 months), were included. PRF targeted the sciatic nerve under imaging guidance; EPR involved endoscopic decompression. Primary outcomes were Numeric Rating Scale (NRS) scores at 3 and 6 months. Secondary outcomes included patient satisfaction, reintervention rates, complications, and the Oswestry Disability Index (ODI), where available. After PSM, 115 patients were analyzed per cohort. Multivariate regression identified the predictors of pain improvement. From 465 eligible patients (PRF 350; EPR 115), after PSM, 230 patients were analyzed (115 per cohort). The baseline NRS score was 7.4 ± 1.4 (PRF) vs. 7.5 ± 1.3 (EPR). At 3 months, EPR showed a lower NRS score (2.6 ± 1.3) compared to PRF (3.2 ± 1.6; = 0.032). At 6 months, the EPR NRS score was 2.2 ± 1.1 vs. 2.9 ± 1.5 for PRF ( = 0.018). EPR had a higher rate of ≥50% NRS score reduction (78% vs. 65%; = 0.041). EPR patients reported higher satisfaction and fewer reinterventions but more complications. Regression analysis identified EPR (OR = 2.15), higher baseline NRS scores, and shorter symptom duration as predictors of improvement. EPR provided superior pain relief compared to PRF at 3 and 6 months, although with a higher risk of complications. PRF remains a safer initial option.