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

2. 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

3. 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.

4. Primary Common Back Trigger Points

5. Referred Common Back Trigger Points

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

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

10. NSAIDS for Myofascial Pain/Trigger Points
2-4 weeks
Ibuprofen mg QID
Naproxen mg BID
Contraindications- renal, GI, CV disease

11. 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
mg 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 mg
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

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

13. 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

14. 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

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

17. Rhomboids Suprispinatus

18. Trapezius Posterior Neck

19. Gluteus Paraspinus

20. Piriformis

21. Mark Your Patient

22. 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

23. One Technique….

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

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