Interventions for Myofacial Pain

Dr (Maj) Pankaj N SurangeMBBS, MD (Anesthesiology), FIPP (Hungary)

Director, Interventional Pain and Spine Centre, New DelhiSecretary, World Institute of Pain, India Chapter

www.ipscindia.com

Mechanism of Action of Trigger point Injections

• Mechanical disruption of the needle going into the trigger point is the most important part of deactivating a trigger point

Indications

• Indicated for patients who have symptomatic active trigger points that produce a twitch response to pressure and create a pattern of referred pain

Trigger point injection-Prerequisites

• Supine –Prone - Sitting

Explain the procedure-allay anxiety

• Sharp pain• Muscle twitching • Unpleasant sensation as the needle contacts the taut

muscular band

Full aseptic precautions

Skin infiltration with 26 g ,half inch needle

• Needle selection• 22-25 G needle• Length depending on the location of trigger

point and body habitus– 1.5 inch to 3.0 inch– Never insert all the way to its hub– inadvertently contact with bone-replace

Technique

• Identification of Trigger points

• Active • Latent

• First the most symptomatic

• Fix the trigger point between two fingers• Ensure adequate tension in the muscle fiber• Advance nedle into the trigger point at an acute angle of 30 degrees to the

skin

• Withdraw the needle to the level of the subcutaneous tissue, then redirected superiorly, inferiorly, laterally and medially, repeating the needling and injection process in each direction.

• Needle all the loci (active spots) within the primary trigger points

• Medications, volume, number and doses

• 1% Lignocaine vs dry needling• 0.2 to 0.3 ml per trigger point• Without epinephrine..

• Botulinum toxin injection does not offer any advantage over saline or local anaesthetic

Ferrante FM, Bearn L, Rothrock R & King L. Evidence against trigger point injection technique for the treatment of cervicothoracic myofascial pain with botulinum toxin type A. Anesthesiology 2005; 103: 377e383.

Graboski CL, Gray DS & Burnham RS. Botulinum toxin A versus bupivacaine trigger point injections for the treatment of myofascial pain syndrome: a randomised double blind crossover study. Pain 2005; 118: 170e175.

• Not more than four trigger point injections per year.

Post Procedure Rehabilitation

• Injection should be followed by three repetitions of the full range of motion of the muscle, meaning it should be shortened or contacted fully, and then stretched to its longest point.

• The patient should then be taught how to stretch the muscle(s) every 60-90 minutes during waking hours.

• Trapezius stretch

• Levator scapuli stretch

• Posterior neck sretch

• Scalene stretch

Modalities

Ultrasound guided Myofacial pain trigger point injection

Ultrasound guided trigger point injection

• Observation of needle placement in real-time

Ultrasound guided trigger point injection

• The possibility of diagnosing musculoskeletal pathologies

Ultrasound guided trigger point injection

• We can avoid injury to important structures around trigger points.

Ultrasound guided trigger point injection

• Avoidance of radiation exposure

• Reduced overall cost

• Portability of equipment within the office setting

Fluoroscopic guided

Complications

• Vasovagal syncope-Resuscitation equipment's

• Pneumothorax- Fluoroscopy guided• Hematoma-apply 2 min pressure• Nerve injury

• Reg Anaesth Pain Manage 2009; 13: 179–83

• Pain Phys 2008; 11: 885–9

• Arch PhysMedRehabil 2009;90: 1829–38

• Obstet Gynecol Clinic North Am 1993; 20: 809–15

Thanks