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Indications

Levator scapulae trigger point injection is a useful diagnostic and therapeutic procedure for myofascial pain.

Techniques

After informed consent is obtained, the patient is placed in a sitting or prone position. The levator scapulae muscle is palpated along the attachment at the C1 to C4 vertebrae and the superior angle of the scapulae. The injection sites are identified as points of maximal tenderness to deep palpation reproducing the patient’s pain complaint. This may or may not result in referred pain. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1½-in. (4-cm), 21- to 25-gauge needle is inserted at the point of maximal tenderness and advanced to the area of the trigger point. After negative aspiration, the trigger point area is injected with 4 mL of local anesthetic (Fig. 67-23).

FIGURE 67-23. Levator scapulae. Trigger points and referred pain patterns.

Comment

The entire body of the levator scapulae muscle should be palpated from origin to insertion and all trigger points injected.

Total injection should not exceed maximum safe dosage. The referred pain pattern for the levator scapular muscle often includes a posterior lateral neck and occipital and temporal regions. The patient should be fully familiar with the stretching program for the levator scapulae muscle and be instructed in a home program. Failure to include a home stretching program usually results in short-term relief.

Complications

Nerve root blockade may result from improper needle placement or injection of large quantities of local anesthetic in the vertebral region. Intraneural injection may result in nerve damage. Severe pain on injection suggests the possibility of an intraneural injection, and the needle should be repositioned immediately.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice

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Indications

Trigger point injection of the trapezius muscle is used to treat myofascial pain.

Techniques

After informed consent is obtained, the patient is placed in the sitting or prone position. The trapezius muscle is palpated. The injection sites are identified as points of maximal tenderness to deep palpation reproducing the patient’s pain complaint. This may or may not result in referred pain. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1½-in. (4-cm), 21- to 25-gauge needle is inserted at the point of maximal tenderness and advanced to the area of the trigger point. After negative aspiration, the trigger point area is injected with 4 mL of local anesthetic (Fig. 67-22).

FIGURE 67-22. Trapezius. Trigger points and referred pain patterns.

Comments

The referred pain pattern for the upper trapezius is often along the posterior lateral aspect of the neck, as well as periarticular and temporal regions. The referred pain pattern for the mid trapezius often involves the shoulder and paraspinal region. The referred pain pattern for the lower trapezius usually involves the paraspinal region. The patient should be fully familiar with the stretching program for the trapezius muscle and be instructed in a home program. Failure to include a home stretching program usually results in short-term relief.

Complications

Significant complications are uncommon with trapezius trigger point injections.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice

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General

Trigger points may occur in any muscle or muscle group of the body. They are commonly found in muscle groups that are routinely overstressed or those that do not undergo full contraction and relaxation cycles. Many trigger points are characterized by pain originating from small circumscribed areas of local hyperirritability involving myofascial structures, resulting in local and referred pain. Pain is aggravated by stretching, cooling, and compression of the affected area, which often gives rise to a characteristic pattern of referred pain (11,12).

Trigger points are best localized by deep palpation of the affected muscle, which reproduces the patient’s pain complaint both locally and in the referred zone. Trigger points are usually a sharply circumscribed spot of exquisite tenderness when they are present; passive or active stretching of the affected muscle routinely increases the pain. When compared with equivalent palpation pressure in normal muscle, the trigger point region displays isolated bands, increased tenderness, and referred pain. The muscle in the immediate vicinity of the trigger point is often described as ropey, tense, or a palpable band. The trigger point is injected after palpation of the affected muscle, and the point of maximal tenderness reproducing the pain complaint is identified. When the point of injection has been determined, it is best marked with the tip of a retracted ballpoint pen or needle hub by pressing the skin to reproduce temporary indentation to mark the point of entry. The patient is prepared in a standard aseptic fashion over an area large is used throughout the procedure. The skin and subcutaneous tissue at the injection site are usually not anesthetized. A 1½- to 2-in. (4- to 5-cm), 22- to 25-gauge needle is advanced into the muscle at the point of maximum tenderness. Before injecting the medication, an attempt should always be made to aspirate to avoid accidental or intravascular injection. Verification that the needle is at the trigger point may be established by the jump sign or reproduction of the pain complaint. Medication should be injected in a fanwise manner in the area of the trigger point.

Indications for Trigger Point Injections

Trigger point injections may be used to determine the source of pain and to provide maximum pain relief from myofascial pain and to facilitate physical therapy for the stretching of trigger points.

Contraindications for Trigger Point Injections

Absolute contraindications to trigger point injection include localized infection, a skin condition that prevents adequate skin preparation, the existence of a tumor at the injection site, history of allergy to local anesthetics, gross coagulation defects, septicemia, or an uncooperative patient.

Complications

The complications associated with trigger point injections include infection, increased pain, local anesthetic overdose, or intravascular injection that can result in CNS toxicity and, in some cases, pulmonary and cardiac arrest. Intraneural injection may result in nerve damage. Severe pain on injection suggests the possibility of an intraneural injection, and the needle should be immediately repositioned. Other complications depend on location of the trigger point injection and are discussed separately.

Techniques

Before the injection, the affected muscle is palpated and the trigger points located and marked. The skin is scrubbed with antiseptic and allowed to dry for 2 minutes. The wearing of sterile gloves is required so that muscle in the sterile field may be palpated throughout the procedure. Before the injection, the trigger point is repalpated and stabilized between the fingers for injection (Fig. 67-20). Routinely, a 1½-in. (4-cm), 21- to 25-gauge needle transverses the skin’s subcutaneous tissue and is advanced smoothly into the area of the trigger point.

FIGURE 67-20. Trigger point palpation. A, B: Palpation and localization of trigger point by rolling beneath two fingers (arrows). C: Stabilization of trigger point for injection by spanning with two fingers (arrows).

Aspiration should be done to ensure there is no intravascular penetration. If this does occur, the needle should be repositioned and aspirated to ensure that blood vessels have been avoided, and then the medication is injected. A fanwise manner of injection often results in the longest pain relief, owing to increased distribution of local anesthetic (Fig. 67-21). The needle is then withdrawn, with pressure applied to minimize bleeding.

FIGURE 67-21. Fanwise injection technique for trigger point.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice