Trigger Point Injections of the Back Clare Romero, CNP & Karen Cardon, MD

What are Trigger Points? Trigger points are hyperirritable areas of contracted muscle fibers that form a nodule you can palpate Caused by: Repetitive overuse injuries Sustained loading Poor posture Direct Injury Poor circulation due to prolonged contraction, remodeling Poor nerve conduction due to prolonged contraction, remodeling Fibrous tissue encapsulates muscle sheath

Types of Trigger Points Central/Primary Trigger Points: well established, most painful. Exist at a neuromuscular point Satellite/Secondary Trigger Points: Referred pain zone. Active Trigger Points: Applies to central & satellite trigger points. TTP, elicits pain pattern, limits ROM. Activated by some type of stimulus or activity. Latent Trigger Points: Feels like a lump or nodule, is not painful nor does it illicit referred pain. Can be activated by stimulus or activity.

Primary Common Back Trigger Points

Referred Common Back Trigger Points

Pharmacologic Management of Myofascial Pain/Trigger Points NSAIDS Muscle Relaxants Injections: Saline Corticosteroids Lidocaine/Bupivicaine Topical Therapies Capcasin Analgesics Methyl Salicylate/Menthol

Non-Pharm Management of Myofascial Pain/Trigger Points Stretch/Foam Roller Trigger Pressure Heat TENS Posture!

NSAIDS for Myofascial Pain/Trigger Points 2-4 weeks Ibuprofen 400-600mg QID Naproxen 220-500mg BID Contraindications- renal, GI, CV disease

Cyclobenzaprine 10mg HS Methocarbamol 750-1500mg Baclofen 5mg Muscle Relaxers for Myofascial Pain/Trigger Points Avoid in adults > 65 Avoid TID dosing if possible Limit duration to 1-2 weeks then PRN for chronic myofascial pain Cyclobenzaprine 10mg HS 750-1500mg TID – QID PRN for 2-3 days then 750mg TID Less sedating than cyclobenzaprine Avoid in adults > 65 & Limit duration to 1-2 weeks then PRN Methocarbamol 750-1500mg TID x 3 days then 10mg TID if needed x 2 weeks Most often used for chronic spasm, but can be used for acute. Not as effective when used PRN No BEERS warning Baclofen 5mg Use when pt reports others are ineffective Can be dose adjusted by 2mg every 3 days up to 6mg per dose Also best used for chronic myofascial pain rather than PRN Tizanidine 2mg

Topical Preparations Topical NSAIDS Topical Analgesics Topical Capcasin Methyl salicylate/menthol Cream

Who is a candidate for TPI? Subjective Complaint: Pts with acute or chronic myofascial pain symptoms. Described as spasm, tight, ache, throbbing, sharp and shooting, often with radiating pain. Sometimes will have decreased ROM due to spasm, pain. Usually history of aggravating event, injury, stress, etc. Pinpoint location Personal History: avoid those with clotting disorders, on blood thinning medication, immunocompromised

Exam/Objective Pt can point with finger the exact location/locations Palpable painful nodule often with spasm/ fasciculation Possibly decreased ROM “TTP right rhomboid, right upper trapezius, thoracic paraspinus”, etc

Informed Consent Informed Consent- Risk of bleeding, infection, bruising, nerve pain, worsening pain, soreness, pneumothorax

Rhomboids Suprispinatus

Trapezius Posterior Neck

Gluteus Paraspinus

Piriformis

Mark Your Patient

Set Up Lidocaine & Bupivicaine or NS Sterile gloves Chlorhexadine 27g 1.5 inch needle Set up sterile field Have assistant (RN, LPN, tech) help you draw up lidocaine/bupivacaine or NS Complete the time out

One Technique…. https://www.youtube.com/watch?v=ch4Otm3C_F4

Post Procedure Care Stretch Heat Will be sore for 2-3 days but effects can last several days to weeks May have some bruising

Follow up Can complete this procedure every 2-4 weeks if using NS or Lidocaine. Recommend not using corticosteroid.