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Myofascial Injections (Trigger Point, Piriformis, Iliopsoas, and Scalene Injections)

Myofascial Injections (Trigger Point, Piriformis, Iliopsoas, and Scalene Injections)

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producecharacteristicreferralpatterns.

•Atriggerpoint(TP)mayoccurinisolationorconcomitantlywithmyofascial

painsyndromeorotherpaingeneratingsyndromes.

•Triggerpointsarediagnosedbyhistoryandphysicalexamination.

•Apatientwillcomplainofalocalizedpainorregionalpainlocatedinor

aroundanyskeletalmuscle.

•Theneck,shouldergirdle,andlowbackarethemostcommonareasinvolved.

Commonlyinvolvedmusclesarethetrapezius,splenii,cervicalandlumbar

paraspinalmuscles,andthequadratuslumborum.

•Onexamination,localizedtautbandsofmusclearenotedandpalpation

producescharacteristicnon-dermatomalreferralpatterns.1

•Triggerpointsmaybeactiveorlatent.Activetriggerpointsproduce

spontaneouspain,whilelatenttriggerpointsproducepainonlywhen

palpated.

•Activetriggerpointsmayresultfromtrauma,overloadoroveruseinjury,or

duetoamusclebeinginaprolongedcontractedorshortenedposition.

•Treatmentsforactivetriggerpointsincludephysicaltherapy(stretchingand

strengthening,conditioning,therapeuticmodalities);triggerpointinjections;

acupuncture;biofeedback;transcutaneousnervestimulation(TENS);and

somemedications.2-4

•Triggerpointinjectionsareintramuscularinjectionsoflocalanestheticwithor

withoutcorticosteroidsthoughttoworkbylocalanestheticeffect,interruption

ofpaintransmission,mechanicaleffectsonthemuscleitself,anddisruption

ofephaptictransmission.



BasicConcernsforInjection

•Immunocompromisedpatients,patientsathighriskforinfection.

•Patientswithmetastaticcancerpainmayhavelocalmassesintheregion.

•Patientsmayhavethrombocytopeniasecondarytochemotherapy.

•Patientswithallodyniaintheareaofinjection.



Contraindications

•Infection,systemicorlocalized



•Coagulopathy

•Distortedorcomplicatedanatomy

•Patientrefusal



PreoperativeConsiderations

•RefertoASRAguidelines,considertherisksandbenefits.

•Anticoagulation—thisislessofaconcernthanforanepidural.

•Physicalexaminationoftheareaforinfection,skinulcerationornecrosis,and

extentofdisease.

•Theabilityofapatienttotolerateasupine,prone,lateraldecubitus,orseated

positionfortheinjection.



Equipments

•Isopropylalcoholorchlorhexidine

•25-gauge1.5-inneedle

•3,5,or10mLsyringeformedications



Medications

•0.25%bupivacaineorotherlocalanesthetic

•Corticosteroid(dexamethasone,triamcinolone,ormethylprednisolone)



Technique

•Themuscleispalpatedandthetriggerpointsareidentifiedandmarked.

UltrasoundmaybeusedtoidentifyhypoechogenicTPs.

•Sterileprepoftheareatobeinjected.

•Theneedleisinsertedintothetriggerpoint.Whenthepatientverbally

identifiesthepainfularea,andafternegativeaspiration,localanestheticis

injectedwithorwithoutsteroid.BotolinumtoxinA,6-12.5unitspermuscle,

totaldosenottoexceed300units.

•Theauthorsuseanonparticulatesteroid,dexamethasone(4mgin30mL

bottleoflocalanesthetic),oralowdoseofparticulatesteroid(eg,20-40mg

ofmethylprednisolonedilutedinthelocalanestheticsolution)mayalsobe



used.

•Painreliefcanbeobtainedwith1to3mLofinjectatepertriggerpointthis

maybedoneinafanwisetechnique.

•Thereshouldbenoparesthesia,blood,orcerebrospinalfluid(CSF)with

needleinsertion.



PostprocedureFollow-Up

Patientshouldbemonitoredcloselyforthefollowing:

•Neurologicsymptoms(weakness,urinaryorbowelincontinence)

•Signsoflocalinfection(warmth,erythema,purulentdrainage,fever)

•Bleeding

•Exacerbationofsymptoms

•Dependingonthelocationoftheinjection,thepatientshouldbeinstructedon

thesignsandsymptomsofpneumothorax(neck,shoulder,thoracic,and

anteriorchestwallinjections),orlocalnerveblockade(eg,inadvertent

mediannerveblockininjectionofflexorcarpiulnaris).



PotentialComplicationsandPitfalls

•Infection

•Bleeding

•Nerveblock

•Hematoma



ClinicalPearls

•Thesuccessoftheprocedureoftheprocedureisdependentonthediagnosis

andlocalizationofthetriggerpoint.

•Patientswithchronicwidespreadpainorpsychologicaldisordersmaybeless

likelytorespondtoTrPs.

•Patient’scanexpectdaystoweeksormonthsof50%to100%relief.Insome

instancesofacuteTrPsintheabsenceofotherpaingenerators,aTrPinjection

iscurativewhencombinedwithphysicaltherapyorahomeexerciseprogram.



PIRIFORMISINJECTIONS

•Piriformissyndrome(PS)isapainfulconditionconsistingofpaininthe

buttockwithorwithoutradiationinthedistributionofthesciaticnerve.

•Itisarelativelyuncommondisorderthoughsomesuggestitmaycontributeto

up8%ofbuttockpain.Piriformissyndromeisadiagnosisofexclusion.

•TherearenostandardizeddiagnosticcriteriaforPS.

•Piriformissyndromecanbeaconsequenceofanabnormalrelationship

betweenthesciaticnerveandthepiriformismuscle(PM),resultingin

irritationofthesciaticnerve.

•Ahypertrophicmuscle,infectionortheinvasionofthemusclebytumorcan

causepressure/irritationonthenerve.

•In78%to84%ofthepopulation,thesciaticnervepassesinfrontandmedial

tothemuscle,butin12%to21%ofindividualsthedividednervepasses

throughorposteriortothemusclebeingexposedtoitscontractionstriggering

sciaticsymptoms.5,6

•Piriformissyndromeshouldbeconsideredinpatientswhopresentwith

buttockpain,tendernesstopalpationoverthePM,andhaveapositive

responsetoseveralprovocativemaneuversincluding5:

Pacesign:painandweaknesswithseatedabductionofthehipagainst

resistance

Laseguesign:painwithunresistedflexion,abduction,andinternalrotation

oftheflexedhip

Freibergsign:painwithforced(ie,againstresistance)internalrotationof

theextendedhip

Due to its small size, its proximity to neurovascular structures, and its deep

location, the piriformis muscle is usually injected under radiographic or

ultrasound guidance. Piriformis injections under CT or electromyographic

guidance have also been described.7,8 In this chapter, we will discuss

flouoroscopicandUS-guidedpiriformisinjections.



BasicConcernsforInjection

Piriformis injections are relatively safe procedures. However, the same

conditionsnotedinthesectionontriggerpointinjectionsarecausesforconcern.



ContraindicationsandPreoperativeConsiderations

Thesearethesameastheonesnotedinthesectionontriggerpointinjections.



Equipments

•Isopropylalcoholorchlorhexidine

•25-gauge1.5-inneedle

•Insulatednerve-stimulating15-cmblockneedle

•Nervestimulator

•3,5,or10mLsyringeformedications



Medications

•0.25%bupivacaineor1%lidocaine

•Corticosteroid(dexamethasone,triamcinolone,ormethylprednisolone)



FluoroscopicTechnique

•Thepatientisplacedproneonafluoroscopytable,andtheinferiormarginof

thesacroiliacjointisimagedandmarked.

•Thepatientispreppedanddrapedinsterilefashion.

•Theneedleinsertionsiteis1to2cmcaudaland1to2cmlateraltothe

inferiormarginoftheSIjoint.

•Theinsertionsiteisanesthetizedwith2to3mLof1%lidocaine.

•Theinsulatedneedleisinsertedandadvancedwiththenervestimulatoron(1

mA,2Hz,0.1ms)untilasciaticnerveevokedmotorresponseisachieved

(dorsiflexion,plantarflexion,eversion,inversion)at0.4to0.6mA.

•Theneedleisslightlywithdrawnuntilthesciaticstimulationdisappears.This

istoavoidintraneuralinjection.

•Steroid(40mgofeithermethylprednisoloneortriamcinolone)plus5mLof

salineisinjectionaroundthesciaticnerve.

•Theneedleispulledback1cmintothebellyofthepiriformismuscleand1to

2mLcontrastisinjected.

•Thecontrastshouldoutlinethepiriformismusclebellywithnosignof



spillage,ie,themarginsareclean(Figure54-1).



Figure54-1.Thepiriformismusclewasoutlinedafteradyeinjection.

(ReproducedwithpermissionfromMackenzie-Brown,ChekkaK,BenzonHT.

Reprintedfrom:Musculoskeletalinjections:Iliopsoas,quadratuslumburom,

piriformis,triggerpointinjections.InHuntoonM,BenzonHT,Narouze,S.

SpinalInjectionsandperipheralnerveblocks.InDeerT.Interventionaland

NeuromodulatoryTechniquesinPainManagement.NewYork:Elsevier–

ChurchillLivingstone,2011.)



•Afterthecharacteristicdyespreadisachieved,thelocalanestheticsolution

andsteroidareadministered.Typically,goodpainreliefcanbeattainedwith

aninjectionof5mLof0.25%or0.5%bupivacaineplus40mgof

methylprednisolone(ortriamcinolone).



Ultrasound-GuidedPiriformisInjections

Ultrasound-guidedtechniquepermitsnotonlyadirectviewofthePM,butalso

examines its relationship to the sciatic nerve and rule out some an anatomic

variation.9

PatientPosition

ThepatientisinpronepositionwiththeUSmachineontheoppositeside.

Equipment

•Acurved,lowfrequencyUSprobe(2-6MHz)isusedtoscanawiderand

deeparea.

•USmachineshouldhaveDopplertohelpidentifyingtheinferiorglutealartery

medialtothesciaticnerveandanteriortothePM.

•A20-to22-gauge10-to12-cm-longneedleisrecommended.

Preparationasdescribedabove.

ScanningProcedure

Thereare2recommendedscanningtechniques:

1.Theclassictechnique

•Positionthetransducerinshort-axis(transverse)overtheSIJwhere

mediallythesacrumwillbevisibleandlaterallytheilium/gluteus

maximusmuscle(GMM)complexwillbeobserved.10

•KeeptheSIJinthecenterofthescreenandmovethetransducercaudal

untilthelateralviewoftheiliumislost,indicatingthatthetransduceris

overthegreatersciaticnotch.

•Inthatpositiontheoperatorwillseethehyperechoeiclateralportionof

thesacrummedially.

•Inthecenteroftheimage,thefollowingarevisualized:theskinandfat

inthenearfield,thentheGMManddeepertoitandoriginatingfromthe

anterior/lateralsacraledgeisthepiriformismusclewiththetypical



longitudinalfibers.

•Clockwiserotationontherightglutealareaandcounterclockwiseonthe

LEFTglutealarea.Movethetransducerslightlylowerandwithmild

clockwiserotation,thesciaticnervewillbevisibledeeperinthemedial

aspectofthepiriformisandtheischiumappearsinitiallyasacurved

hyperechoeicline(posterioracetabulum)andmorecaudallyitbecomesa

flatlinedeepertothepiriformis(Figure54-2).



Figure54-2.Thepiriformismuscleovertheischiumandthesciaticnerveand

underthegluteusmaximusmuscle(GMM).Thereddashedarrowshowstheinplaneneedletrajectory.

2.Alternativetechnique

•Placethetransduceroverthelinebetweenthegreatertrochanterandthe

ischialtuberosity.



•Oncethesciaticnerveisidentified,itisfollowedcephaladuntilthePM

andtheGMMareseenoverthesciaticnerve.



TwoPearlswithEitherApproach

•ToconfirmtheviewofthePM,flexthekneein90degreesandrotatethehip

ofthepatientinternally/externallytoseethePMslidingovertheischiumas

opposedtothestablepositionoftheGMM(Figure54-3).



Figure54-3.Typicalmovementtoidentifythepiriformismuscleoverthe

ischiumwhenflexingthekneein90degreesandrotatingthehipinternally

externally.

•Whenobservingthesciaticnotchitisusefultoidentifytheischialspinesince

othermusclesinsimilarpositiontothePMinsertinthearea(ie,thegemelli

andobturatormuscles)andshouldbedifferentiatedfromthePM.



NeedleInsertion

•ThemoreperpendiculartheneedleistotheUSbeam,thebetteristheview.

•Withthepatientinproneposition,thePMrunsalmosthorizontalbetweenthe

sacrumandthefemur.

•Wesuggestalateraltomedial,in-planeapproachwiththeneedleenteringthe

skinat3to4cmlateraltothelateraledgeofthetransducertoachievearather

flattrajectorythatmakesitmucheasiertosee.

•Afterlocalanestheticinfiltration,theneedleshouldcrosstheskinandfatina

lateral-to-medial,posterior-to-anteriordirection,entertheGMMandthenthe

PMinitsmedialhalf,whereitisthicker.

•Hydrodissectionwithnormalsaline(NS)1mLmayhelpinconfirmingthe

positionofthetipbeforeinjectingintothePM.

•Asteroid(methylprednisoloneortriamcinolone)withlocalanesthetic

bupivacaineorlidocaineistheninjected.



PostprocedureFollow-Up

Patientshouldbeadvisedtocallpainmedicineserviceforanyprocedurerelated

complicationsand/oranyunexpectedneurologicaldeficit.Thoughcomplications

areuncommon,patientshouldbemonitoredcloselyforfollowing:

•Neurologicsymptoms(weakness,urinaryorbowelincontinence)

Itiscommonforthepatienttohaveweaknessornumbnessinthe

distributionofthesciaticnervefortheexpecteddurationofthelocal

anesthetic.

•Signsoflocalinfection(warmth,erythema,purulentdrainage,fever)

•Bleeding

•Exacerbationofsymptoms



PotentialComplicationsandPitfalls

Sameasinthesectionontriggerpointinjectionsplussciaticnerveblockade.



ClinicalPearls

•Thesuccessoftheprocedureisdependentonthediagnosisofpiriformis



syndrome.

•PatientswithotherspineorSIjointcomorbidities,chronicwidespreadpainor

psychologicaldisordersmaybelesslikelytorespond.



ILIOPSOASINJECTIONS

Overview

Pain emanating from the iliopsoas muscle is relatively uncommon, but a very

real cause of low back, hip, or inguinal pain. Patients typically present with

unilaterallowbackoranteriorhippain,thoughpaincanfrequentlyreferintothe

thighoringuinalarea.

Onexamination:

•Anantalgicgaitmaybenotedasthepatiententerstheexaminationroom,due

toashortenedstrideontheaffectedside.

•Thepatientmayalsohavepainand/orweaknesswhensquattingtositorwhen

transitioningfromaseatedpositiontoastandingone.

•Thepsoasmusclecanbepalpateddeepintheabdomen,medialtotheanterior

superioriliacspine,whentheipsilateralhipisflexed.

•Painonpalpationwhileflexingthehipagainstresistanceisanexcellent

diagnostictoolforpsoasmyopathy,butmaybeextremelyuncomfortablefor

thepatientduetopainandprivacyreasons.

Provocativetests:

•Arenotspecificfortheiliopsoasmuscle,butcanbeusedtoaidinthe

diagnosisviaactiveandpassiveextensionofapainfulmuscle.11

•Thomastest—inabilityofthepatienttocompletelyextendtheaffectedhip

whenlyingsupine,withcontralateralhipfullyflexed,duetotightenedhip

flexors

•Yeomantest—painwithpassiveextensionofaffectedhipwhenlyingprone,

typicallyasacroiliacjointtest,butcancauseanteriorhippainwithpassive

iliopsoasextension

•Gaenslentest—painwithmaximalextensionofaffectedhip(leghangsoff

examinationtable)andmaximalflexionofcontralateralhip(kneeheldto

chest),typicallyasacroiliacjointtest,butcancauseanteriorhippainwith

passiveiliopsoasextension



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Myofascial Injections (Trigger Point, Piriformis, Iliopsoas, and Scalene Injections)

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