Interventions for Myofacial Pain           Dr (Maj) Pankaj N Surange          MBBS, MD (Anesthesiology), FIPP (Hungary)   ...
Mechanism of Action of          Trigger point Injections• Mechanical disruption of the needle going  into the trigger poin...
Indications• Indicated for patients who have  symptomatic active trigger points that  produce a twitch response to pressur...
Trigger point injection-     Prerequisites• Supine –Prone - Sitting
Explain the procedure-allay anxiety• Sharp pain• Muscle twitching• Unpleasant sensation as the needle contacts the taut  m...
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       ...
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 p...
• Withdraw the needle to the level of the subcutaneous  tissue, then redirected superiorly, inferiorly, laterally and  med...
• Medications, volume, number and doses               • 1% Lignocaine vs dry needling               • 0.2 to 0.3 ml per tr...
• 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 muscl...
• 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 poin...
Ultrasound guided trigger point                injection• Avoidance of radiation exposure• Reduced overall cost• Portabili...
Fluoroscopic guided
Complications• Vasovagal syncope-Resuscitation  equipments• Pneumothorax- Fluoroscopy guided• Hematoma-apply 2 min pressur...
• Reg Anaesth Pain Manage 2009; 13: 179–83• Pain Phys 2008; 11: 885–9• Arch PhysMedRehabil 2009;90: 1829–38• Obstet Gyneco...
Thanks
Trigger point injection
Trigger point injection
Trigger point injection
Trigger point injection
Trigger point injection
Trigger point injection
Trigger point injection
Trigger point injection
Trigger point injection
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Trigger point injection

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Trigger points are commonly seen in patients with myofascial pain which is responsible for localized
pain in the affected muscles as well as referred pain patterns. Correct needle placement in a
myofascial trigger point is vital to prevent complications and improve efficacy of the trigger point
injection to help reduce or relieve myofascial pain
Office based ultrasound-guided injection techniques for musculoskeletal
disorders have been described in the literature with regard to tendon, bursa, cystic, and
joint pathologies. For the interventionalist, utilizing ultrasound yields multiple advantages technically
and practically, including observation of needle placement in real-time, ability to perform
dynamic studies, the possibility of diagnosing musculoskeletal pathologies, avoidance of radiation
exposure, reduced overall cost, and portability of equipment within the office setting.

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  • Not yet clearly understood.Initially some thought that it is actually fibrositis, so injecting steroids causes relaxation. Some thought that it is ectopic firing of the nerve endings so local anesthetics causes stabilization…..but today the most acceptable theory is mechanical disruption of the muscle fibre causes deactivation of trigger points
  • Primarily indicated for active trigger points. Satellite trigger points are also active tps so inj in these is alos an indication. As regrds to latent tps we don’t have conclusive evidence to support to address latent tps.
  • Depends on the location of tps and comfort of the patient.
  • Trigger point injection

    1. 1. Interventions for Myofacial Pain Dr (Maj) Pankaj N Surange MBBS, MD (Anesthesiology), FIPP (Hungary) Director, Interventional Pain and Spine Centre, New Delhi Secretary, World Institute of Pain, India Chapter www.ipscindia.com
    2. 2. 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
    3. 3. Indications• Indicated for patients who have symptomatic active trigger points that produce a twitch response to pressure and create a pattern of referred pain
    4. 4. Trigger point injection- Prerequisites• Supine –Prone - Sitting
    5. 5. Explain the procedure-allay anxiety• Sharp pain• Muscle twitching• Unpleasant sensation as the needle contacts the taut muscular band
    6. 6. Full aseptic precautions
    7. 7. Skin infiltration with 26 g ,half inch needle
    8. 8. • 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
    9. 9. Technique• Identification of Trigger points • Active • Latent• First the most symptomatic
    10. 10. • 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
    11. 11. • 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
    12. 12. • 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 anaestheticFerrante FM, Bearn L, Rothrock R & King L. Evidence against trigger point injection technique for the treatment ofcervicothoracic 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 thetreatment of myofascial pain syndrome: a randomised double blind crossover study. Pain 2005; 118: 170e175.
    13. 13. • Not more than four trigger point injections per year.
    14. 14. 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.
    15. 15. • Trapezius stretch
    16. 16. • Levator scapuli stretch
    17. 17. • Posterior neck sretch
    18. 18. • Scalene stretch
    19. 19. Modalities
    20. 20. Ultrasound guided Myofacial pain trigger point injection
    21. 21. Ultrasound guided trigger point injection• Observation of needle placement in real- time
    22. 22. Ultrasound guided trigger point injection• The possibility of diagnosing musculoskeletal pathologies
    23. 23. Ultrasound guided trigger point injection• We can avoid injury to important structures around trigger points.
    24. 24. Ultrasound guided trigger point injection• Avoidance of radiation exposure• Reduced overall cost• Portability of equipment within the office setting
    25. 25. Fluoroscopic guided
    26. 26. Complications• Vasovagal syncope-Resuscitation equipments• Pneumothorax- Fluoroscopy guided• Hematoma-apply 2 min pressure• Nerve injury
    27. 27. • 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
    28. 28. Thanks
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