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.

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. 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. 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. Trigger point injection-
Prerequisites
• Supine –Prone - Sitting

5. Explain the procedure-allay anxiety
• Sharp pain
• Muscle twitching
• Unpleasant sensation as the needle contacts the taut
muscular band

6. Full aseptic precautions

7. Skin infiltration with 26 g ,half inch needle

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. Technique
• Identification of Trigger points
• Active
• Latent
• First the most symptomatic

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. • 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

13. • 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.

14. • Not more than four trigger point injections
per year.

15. 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.

16. • Trapezius stretch

17. • Levator scapuli stretch

18. • Posterior neck sretch

19. • Scalene stretch

20. Modalities

21. Ultrasound guided Myofacial pain trigger
point injection

22. Ultrasound guided trigger point
injection
• Observation of needle placement in real-
time

23. Ultrasound guided trigger point
injection
• The possibility of diagnosing musculoskeletal
pathologies

24. Ultrasound guided trigger point
injection
• We can avoid injury to important structures
around trigger points.

25. Ultrasound guided trigger point
injection
• Avoidance of radiation exposure
• Reduced overall cost
• Portability of equipment within the office
setting

26. Fluoroscopic guided

27. Complications
• Vasovagal syncope-Resuscitation
equipment's
• Pneumothorax- Fluoroscopy guided
• Hematoma-apply 2 min pressure
• Nerve injury

28. • 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

29. Thanks