Lidocaine vs. Bupivacaine for Trigger Point Injections

Lidocaine is the preferred choice over bupivacaine for trigger point injections due to its superior safety profile and comparable efficacy. 1

Safety Considerations

Bupivacaine is known to be more potently toxic than other local anesthetics like lidocaine, with a higher risk of cardiac complications 1
Bupivacaine can cause more severe systemic toxicity including hypotension, arrhythmias, and cardiac/respiratory arrest compared to lidocaine 1
The 2023 AHA guidelines specifically note that bupivacaine has greater affinity and binding duration to cardiac sodium channels, making it a more potent cardiotoxin than lidocaine 1
Lidocaine has a better established safety record for trigger point injections with minimal serious adverse effects 1, 2

Both lidocaine and bupivacaine have demonstrated efficacy in reducing pain from trigger points 2, 3
A randomized controlled trial comparing lidocaine patches, placebo patches, and bupivacaine injections found that both active treatments significantly decreased pain and increased pain thresholds 2
Lidocaine injections have been shown to reduce the intensity and duration of post-injection soreness compared to dry needling techniques 4
A 2021 study demonstrated that lidocaine injections to trigger points were effective in reducing neck pain and disability with benefits lasting at least three months 5

Lidocaine has a faster onset of action compared to bupivacaine, providing more immediate relief 1
Lidocaine causes less post-injection soreness than alternatives, improving patient comfort 4
Lidocaine can be buffered with sodium bicarbonate to decrease injection pain, while bupivacaine should not be buffered as it may precipitate and decrease efficacy 1
In cases of local anesthetic systemic toxicity (LAST), lidocaine toxicity is generally easier to manage than bupivacaine toxicity 1

For trigger point injections, 1-2% lidocaine is typically used 5
When using lidocaine with epinephrine, the lowest effective concentration should be used to provide pain control and vasoconstriction 1
For patients requiring multiple trigger point injections, careful attention should be paid to total dose to avoid systemic toxicity 1
The addition of sodium bicarbonate to lidocaine (in a 1:9 or 1:10 ratio) can significantly decrease injection pain 1

For patients with extensive trigger points requiring higher volumes of anesthetic, lidocaine is safer due to its wider therapeutic window 1
In patients with cardiac conditions, lidocaine presents less risk than bupivacaine 1
For patients experiencing significant post-injection soreness with lidocaine, consider using a lower concentration or adding triamcinolone to the injection 6
If longer duration of action is needed, consider using ropivacaine as an alternative to bupivacaine, as it has an intermediate cardiac toxicity profile between lidocaine and bupivacaine 1

Exceeding maximum safe doses of local anesthetics, especially when treating multiple trigger points in one session 1
Using bupivacaine in patients with known cardiac conditions 1
Failing to have lipid emulsion 20% readily available when performing trigger point injections with any local anesthetic 1
Injecting without eliciting local twitch responses, which are essential for immediate therapeutic effect 4