Rheumatology Book

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Trigger Point Injection

Aka: Trigger Point Injection
  1. See Also
    1. Lower Cervical Intramuscular Injection
  2. Indication
    1. Tension Headache (Occipital Headache)
      1. Trigger Point Injection at trapzius insertion
    2. Myofascial Pain Syndrome
      1. Symptomatic active Trigger Point AND
      2. Twitch response to pressure with referred pain
  3. Contraindications
    1. Known Bleeding Disorder
    2. Anticoagulation (includes Aspirin in last 3 days)
    3. Local or systemic infection
    4. Acute Trauma at muscle site
    5. Anesthetic allergy
    6. Unsafe injection site
      1. Example: Intercostal space (risk of Pneumothorax)
  4. Mechanism
    1. Mechanical disruption of Trigger Point
    2. Dry needle "poking" of Trigger Points is also effective
      1. However, may result in more post-injection soreness
  5. Preparation
    1. Solution
      1. Bupivicaine (Sensorcaine) 0.25%: 5 cc total
        1. May be used alone (effective) or with Corticosteroid
      2. Triamcinolone (Kenalog) 40 mg/ml: 1 cc
        1. Some studies demonstrate no additional benefit with Corticosteroid versus anesthetic alone
        2. Mechanism of Trigger Point Injection effect is likely more than antiinflammatory activity
    2. Needle selection
      1. Select needle of adequate length
        1. Prevents burying needle to hub (risk or breakage)
      2. Select needle of adequate gauge
        1. Allows for necessary mechanical disruption
        2. Less likely to be deflected from taut muscle
      3. Needle examples
        1. Shallow sites
          1. Optimal: 25-27 gauge 1.25 to 1.5 inch needle
          2. Alternative: Tuberculin syringe (5/8 inch)
        2. Deeper sites or obese patient
          1. Spinal needle (21 gauge 2.5 inch needle)
  6. Technique
    1. Position patient comfortably
    2. Patient identifies one to four Trigger Points
    3. Anticipate initial increased pain on injection
      1. Local twitch and referred pain confirms placement
      2. Injecting near Trigger Point may cause irritation
    4. Start with most tender spot in Trigger Point
      1. Localize most tender spot within taut muscle-fibers
      2. Fix tender spot between fingers (1-2 cm in size)
        1. Prevents from rolling away from needle
        2. Controls subcutaneous bleeding
    5. Cleanse overlying skin with Alcohol swab, betadine or hibiclens
    6. Inject Trigger Point
      1. Select needle as above
      2. Warn patient of possible pain on injection
      3. Direct needle at 30 degree angle off skin
        1. Insert needle into skin 1-2 cm from Trigger Point
        2. Advance needle into Trigger Point
      4. Use 0.3 to 0.5 cc (up to 1 cc/site) anesthetic at each Trigger Point
      5. Redirect needle and reinject
        1. Withdraw needle to subcutaneous tissue
        2. Redirect needle into adjacent tender areas
        3. Repeat until local twitch or tautness resolves
    7. Hold direct pressure at injection site for 2 minutes
      1. Prevents hematoma formation
    8. Repeat procedure for other Tender Points
    9. Patient gently stretches injected areas
      1. Full active range of motion in all directions
      2. Repeat range of motion three times after injection
  7. Management: Post-Procedure Instructions (Reduce postinjection flare)
    1. Patient avoids over-using injected area for 3-4 days
      1. Maintain active range of motion of injected muscle
    2. Patient applies ice to injected areas for a few hours
    3. Anticipate post-injection soreness for 3-4 days
  8. Complications
    1. Local Skin Infection at injection site
    2. Local hematoma at injection site
  9. Course
    1. Expect 2-4 months of benefit after injection
  10. Precautions
    1. Avoid repeat injection if unsuccessful on 2-3 attempts
    2. Re-evaluate for possible repeat injection after 4 days
  11. References
    1. Ruoff in Pfenninger (1994) Procedures, Mosby, p. 164-7
    2. Sola in Roberts (1998) Procedures, Saunders, p. 890-901
    3. Strayer in Herbert (2016) EM:Rap 16(11): 1-2
    4. Alvarez (2002) Am Fam Physician 65(4):653-60 [PubMed]
    5. Fomby (1997) Phys Sportsmed 25(2):67-75 [PubMed]

Injection of trigger points (C0185340)

Definition (ALT) Injecting a substance into a hyperirritable point of a client/patient's muscle bundle. Service is billed per injection.
Concepts Therapeutic or Preventive Procedure (T061)
SnomedCT 150863007, 39074004
LNC LP157797-4
English Trigger point infiltration, injection of trigger point (treatment), injection of trigger point, trigger point injection, injection point trigger, injections point trigger, Trigger point infiltration (procedure), Injection of trigger points, TPI - Trigger point injection, Trigger point injection, Injection of trigger points (procedure), Trigger-point injection each injection, trigger-point njxn ea.njxn
Spanish inyección en puntos gatillo, inyección en zonas reflexógenas (procedimiento), inyección en zonas reflexógenas
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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