Trigger Point Injections
Why Trigger Points?
Trigger points are small painful areas that can usually be localized to a fingertip-width or less. They are mainly located on the backside of the body along the spine and pelvis or the shoulder girdle. They can arise from nerve, muscle, or ligament irritation. They tend to be persistent and aggravating rather than disabling. Treatment methods have included heat or cold, stretching and strengthening, physical therapy, massage, even acupuncture. But trigger point injections are a time-honored way to diagnose the condition and then treat the problem. Over the years many different solutions have been proposed to combat this irritating and recurrent problem.
Hypertonic dextrose, 15-25% as opposed to 5% has been used for decades to create an inflammatory response and stimulate the injured tissue to heal using the body’s own repair pathways. It is commonly referred to as prolotherapy. Dextrose tends to be more effective over ligaments and muscles rather than by nerves. Six weeks between injection is the norm to allow the body time to generate a healing response.
Bupivacaine is a common, long-acting anesthetic agent in the novacaine family which numbs the tissue around the trigger point. In theory, the vicious circle of pain then spasm and more pain can be broken thus creating a cure. Bupivacaine works equally well around nerves and other tissues, but its strength lies in its numbing abilities and in its long-lasting effect, up to 12 hours, as opposed to one hour for novacaine. It can be injected daily if needed.
Sarapin is an aqueous solution derived from the pitcher plant. It is effective in pain management due to its ability to initiate the body’s own natural healing properties. It does have anesthetic properties similar to procaine. It is thought that sarapin has selective action on the C pain fibers and lacks effect on the motor fibers making it excellent for treatments of neuralgic pain without creating a motor deficit such as procaine might. Toxicity testing revealed that it is essentially harmless, similar to dextrose.
Cortisone is a naturally produced human steroid which is also commercially made for medical use. It has highly anti-inflammatory properties, but it does have a certain degree of tissue toxicity. It has been a standard in the medical community to reduce local inflammation, but it is usually injected with a novocaine type anesthetic agent because it tends to burn when injected. However, cortisone gives excellent results in trigger point injections. But with this effectiveness comes some potential side effects. This may include local subcutaneous fat destruction and skin thinning or even local tendon damage if injected too frequently. It has been implicated in raising blood sugar in diabetics, albeit transiently.
For persistent spasm which is not solved with the above medications, Botox or Xeomin have been increasing used for trigger points. By paralyzing the muscle spasm over trigger points for longer periods than a few hours with cortisone preparations, these neuromodulators have shown great promise in more complete pain relief and longer lasting relief, even up to three months of effect. We find that we are increasingly using Xeomin in Trigger Point Injection Therapy.