What is the recommended protocol for administering trigger point injections to a patient with localized lower back and trapezius pain?

Trigger Point Injection Protocol for Lower Back and Trapezius Pain

Trigger point injections with local anesthetic are strongly recommended for treating chronic back pain, with careful attention to proper technique and patient positioning to ensure optimal outcomes.

Identification and Preparation

• Confirm the exact location of trigger points by having the patient identify the most painful areas in the lower back and trapezius
• Palpate for:
  • Taut bands within the muscle
  • Tender nodules
  • Pain reproduction when pressure is applied
  • Referred pain patterns typical of these muscle groups

Injection Technique

Materials

• 25-28G needle (length appropriate for the muscle depth)
• 0.5% lidocaine without steroids 1
• Sterile preparation supplies

Procedure Steps

1. Position the patient:

   • For trapezius: seated with arms relaxed at sides
   • For lower back: prone or in lateral decubitus position

2. Identify and mark trigger points after careful palpation

3. Prepare the skin with antiseptic solution

4. Insert the needle perpendicular to the skin directly into the trigger point

   • Depth typically 1-1.5 cm depending on patient's body habitus 1
   • Use a 10°-20° angle with a 2-hand technique for better control 1

5. Elicit a local twitch response (muscle fasciculation) which is essential for effective treatment 2

   • This requires multiple needle insertions in different directions within the trigger point

6. Inject small amounts (0.5-1 mL) of 0.5% lidocaine per trigger point

   • Total volume should not exceed recommended maximum doses per FDA guidelines 3

7. Withdraw the needle immediately after injection 1

Post-Injection Considerations

• Monitor the patient for 15-30 minutes after the procedure for any adverse reactions

• Warn patients about post-injection soreness which typically:

  • Develops within 2-8 hours after injection
  • May last 24-48 hours
  • Is different from their original myofascial pain 2

• Advise gentle stretching exercises for the injected muscles

• Recommend application of heat or ice as needed for post-injection soreness

Expected Outcomes

• Immediate pain relief should be expected if local twitch response was elicited 2
• Significant improvement in pain scores and range of motion should occur within 7-10 days 4
• Multiple sessions may be required for chronic cases

Special Considerations

• For patients with fibromyalgia in addition to myofascial pain, be aware that:

  • Pain relief may be delayed and less pronounced
  • Post-injection soreness may be more severe and last longer 5

• For difficult or deep trigger points in the quadratus lumborum:

  • Consider using longer needles (60-90mm)
  • Use anatomical landmarks for proper placement 6

• Avoid using steroid injections for trigger points as they provide no additional benefit and may increase risk of complications 1

Safety Precautions

• Have resuscitative equipment, oxygen, and emergency medications readily available 3
• Use caution with total dose of local anesthetic to avoid systemic toxicity
• Monitor for signs of CNS toxicity including:
  • Restlessness, anxiety, incoherent speech
  • Lightheadedness, numbness, tingling of mouth and lips
  • Metallic taste, tinnitus, dizziness, blurred vision 3

By following this protocol and eliciting local twitch responses during injection, you can provide effective pain relief for your patient's lower back and trapezius trigger points.