title: Ultrasound-guided trigger point injections in the cervicothoracic musculature: a new and unreported technique.
abstract: BACKGROUND
  Myofascial pain is defined as pain that originates from myofascial trigger points in skeletal muscle. It is prevalent in regional musculoskeletal pain syndromes, either alone or in combination with other pain generators. The myofascial pain syndrome is one of the largest groups of under diagnosed and under treated medical problems encountered in clinical practice. 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. In obese patients, these injections may not reach the target tissue. In the cervicothoracic spine, a misguided or misplaced injection can result in a pneumothorax. Here, we describe an ultrasound-guided trigger point injection technique to avoid this potential pitfall. 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. To our knowledge, the use of ultrasound guidance in performing trigger point injection in the cervicothoracic area, particularly in obese patients, has not been previously reported.
  
  
  METHODS
  A palpable trigger point in the cervicothoracic musculature was localized and marked by indenting the skin with the tip of a plastic needle cover. The skin was then sterile prepped. Then, using an ultrasound machine with sterile coupling gel and a sterile latex free transducer cover, the musculature in the cervicothoracic spine where the palpable trigger point was detected was visualized. Then utilizing direct live ultrasound guidance, a 25-gauge 1.5 inch needle connected to a 3 mL syringe was placed into the muscle at the exact location of the presumed trigger point. This guidance helps confirm needle placement in muscle tissue and not in an adipose tissue or any other non-musculature structure.
  
  
  RESULTS
  The technique is simple to be performed by a pain management specialist who has ultrasound system training.
  
  
  CONCLUSIONS
  Ultrasound-guided trigger point injections may help confirm proper needle placement within the cervicothoracic musculature. The use of ultrasound-guided trigger point injections in the cervicothoracic musculature may also reduce the potential for a pneumothorax by an improperly placed injection.
authors.affiliation: Florida Spine Institute, Clearwater, FL, USA. cbarragan@floridaspineinstitute.com
authors.forename: Kenneth P
authors.initials: KP
authors.lastname: Botwin
authors.forename: Kavita
authors.initials: K
authors.lastname: Sharma
authors.forename: Romeo
authors.initials: R
authors.lastname: Saliba
authors.forename: Bharat C
authors.initials: BC
authors.lastname: Patel
mesh_terms: D000305:Adrenal Cortex Hormones / Q000008:administration & dosage; D000779:Anesthetics, Local / Q000008:administration & dosage; D006801:Humans; D007273:Injections, Intramuscular / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods; D009209:Myofascial Pain Syndromes / Q000000981:diagnostic imaging* / Q000188:drug therapy / Q000503:physiopathology; D009334:Neck Muscles / Q000000981:diagnostic imaging* / Q000187:drug effects / Q000503:physiopathology; D019547:Neck Pain / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000503:physiopathology; D009339:Needles / Q000009:adverse effects / Q000592:standards; D009407:Nerve Block / Q000295:instrumentation / Q000379:methods; D019148:Neuromuscular Blockade / Q000295:instrumentation / Q000379:methods; D009466:Neuromuscular Blocking Agents / Q000008:administration & dosage; D011030:Pneumothorax / Q000209:etiology / Q000517:prevention & control; D011183:Postoperative Complications / Q000517:prevention & control; D013909:Thorax / Q000000981:diagnostic imaging / Q000503:physiopathology; D014463:Ultrasonography / Q000379:methods*
chemical_list: D000305:Adrenal Cortex Hormones; D000779:Anesthetics, Local; D009466:Neuromuscular Blocking Agents