Trigger Point Excision - New Forgotten Treatment

Below you will find a new (or well forgotten old) treatment of trigger points.  Most of my pain management and spine surgeon colleagues never heard of it.  Do not be surprised if you never did either.  Please read below.

Management of trigger points is a challenging problem. There is limited research on etiology of trigger points. There are multiple theories on development of Myofascial Syndrome and trigger points.  There is central nervous system theory, Muscle compression, Ischemic, Mitochondrial theory etc.

Traditional Trigger Point Treatments

The treatment is usually limited to attempts to reduce stress, overuse, anti-inflammatory medications, muscle relaxants, antidepressants, neuroleptics, acupuncture, osteopathic manipulations, massage, heat and cold applications, ultrasound, nerve stimulators, dry needling and trigger point injections with local anesthetic or steroids. 

The goal of all therapies is to disrupt the taut band within the fascia or the muscle itself.  Some patients end up having spinal surgeries in attempt to reduce pain. 

Having so many treatment options for a single condition tells you that none of them produce great and reliable results. 

The basic anatomic cause of trigger point is a scar or scar-like tissue formation that creates thickening of the fascia on top of the muscle or inside of it.  There are many complex physiologic reasons why that is happening, but the final anatomic structure or abnormality is the same – tight scar lake band or knot. 

Trigger Point Excision Approach

My approach adds additional minimally invasive way to manage trigger points - by excising diseased fascia through a small, about 1 inch, incision.  It was originally pioneered by a retired Texas plastic surgeon over 30 years ago, who performed over 2000 procedures with internal success rate of 98% but it never became mainstream.

The procedure is elegant and simple.  The trigger point is identified with manual examination and / or ultrasound and is tagged and internally marked.   Through a small incision diseased fascia and sliver of muscle are gently removed and then muscle defect is repaired / reconstructed if necessary.  

The diseased fascial tissues can enclose or entrap surrounding nerves.  Chronic nerve entrapment within the fascial tissues is one of the main causes of chronic pain. Some of these nerves can be anatomically identifiable, such as Spinal accessory nerve, Greater or Lesser Occipital nerves and others.  Other nerves are much smaller and are not easily visible.

Physiology Behind Trigger Point Excision Surgery 

Physiologic basis of this procedure is similar to other nerve release surgeries and migraine surgery.  For the last 10 years or so I have seen plastic surgeons successfully treat Migraine with decompression or release of "triggering nerves", while neurologists deemed it unnecessary because they believed in central nervous system theory of Migraine process.

At the end plastic surgeons proved that the success rate of the Migraine surgery was so significant that it could not be ignored any longer.

Trigger point excision procedure is very similar to Migraine surgery but it is used in a different areas of the body and allows for release different nerves.

How Procedure is Performed

The procedure is usually performed in the surgery center or hospital on outpatient basis under local anesthesia and mild sedation and takes about an hour. In most cases general anesthesia and overnight stay are not required.

Expectation from Trigger Point Excision Surgery

Most patients experience significant improvement of trigger point symptoms.  The trigger point pain is temporarily replaced with usual postsurgical pain, which is much different then trigger point pain.  Recovery from surgery takes about 1-3 weeks depending on complexity, amount of fascia removed and other factors.

Procedure can be performed on any body part with palpable stable trigger point location.

If you had 2 or more unsuccessful trigger point injections and failed other non-surgical methods for 6 month or more, or if you do not want to continue taking numerous medications for the rest of your life or have spinal surgery, give our office a call to schedule your evaluation to see if you are a candidate for minimally invasive trigger point excision procedure.

Supporting references

Pianta WR and Burkhead WZ Jr Case Report Open Access Myofascial Pain Syndrome - A Surgical Perspective Journal of Pain & Relief 

                      For Full Article Click Here

N Ake Nystrom 1, Lloyd P Champagne, Michael Freeman, Elisabeth Blix  Surgical fasciectomy of the trapezius muscle combined with neurolysis of the Spinal accessory nerve; results and long-term follow-up in 30 consecutive cases of refractory chronic whiplash syndrome. J Brachial Plex Peripher Nerve Inj 2010 Apr 7;5:7.

Rolv-Ole Lindsetmo 1, Jonah Stulberg  Chronic abdominal wall pain--a diagnostic challenge for the surgeon Am J Surg 2009 Jul;198(1):129-34

Lisa Gfrerer 1, Marek A Hansdorfer ¹, Ricardo Ortiz ¹, Christian Chartier ^2 1, Kassandra P Nealon ¹, William G Austen Jr ¹ Muscle Fascia Changes in Patients with Occipital Neuralgia, Headache, or Migraine Plast Reconstr Surg 2021 Jan 1;147(1):176-180

Ali Hendi 1, Peter T Dorsher, Thomas D Rizzo Jr, Lawrence E Gibson Subcutaneous trigger point causing radiating postsurgical painArch Dermatol 2009 Jan;145(1):52-4.

Dash KS, Janis JE, Guyuron B. The lesser and third occipital nerves and migraine headaches. Plast Reconstr Surg. 2005;115:1752–1758; discussion 1759–1760.

Ducic I, Moriarty M, Al-Attar A. Anatomical variations of the occipital nerves: Implications for the treatment of chronic headaches. Plast Reconstr Surg. 2009;123:859–863; discussion 864.

Junewicz A, Katira K, Guyuron B. Intraoperative anatomical variations during greater occipital nerve decompression. J Plast Reconstr Aesthet Surg. 2013;66:1340–1345.

Lee M, Brown M, Chepla K, et al. An anatomical study of the lesser occipital nerve and its potential compression points: Implications for surgical treatment of migraine headaches. Plast Reconstr Surg. 2013;132:1551–1556.

Mosser SW, Guyuron B, Janis JE, Rohrich RJ. The anatomy of the greater occipital nerve: Implications for the etiology of migraine headaches. Plast Reconstr Surg. 2004;113:693–697; discussion 698–700.

Peled ZM, Pietramaggiori G, Scherer S. Anatomic and compression topography of the lesser occipital nerve. Plast Reconstr Surg Glob Open. 2016;4:e639.

Janis JE, Hatef DA, Ducic I, et al. The anatomy of the greater occipital nerve: Part II. Compression point topography. Plast Reconstr Surg. 2010;126:1563–1572.

Janis JE, Hatef DA, Reece EM, McCluskey PD, Schaub TA, Guyuron B. Neurovascular compression of the greater occipital nerve: Implications for migraine headaches. Plast Reconstr Surg. 2010;126:1996–2001.

Stecco A, Pirri C, Stecco C. Fascial entrapment neuropathy. Clin Anat. 2019;32:883–890.

Adigozali H, Shadmehr A, Ebrahimi E, Rezasoltani A, Naderi F. Ultrasonography for the assessment of the upper trapezius properties in healthy females: A reliability study. Muscles Ligaments Tendons J. 2016;6:167–172.

Salavati M, Akhbari B, Ebrahimi Takamjani I, Ezzati K, Haghighatkhah H. Reliability of the upper trapezius muscle and fascia thickness and strain ratio measures by ultrasonography and sonoelastography in participants with myofascial pain syndrome. J Chiropr Med. 2017;16:316–323.

Gfrerer L, Lans J, Faulkner HR, Nota S, Bot AGJ, Austen WG Jr. Ability to cope with pain puts migraine surgery patients in perspective. Plast Reconstr Surg. 2018;141:169–174.

Donato G, Galasso O, Valentino P, et al. Pathological findings in subsynovial connective tissue in idiopathic carpal tunnel syndrome. Clin Neuropathol. 2009;28:129–135.

van Doesburg MH, Mink van der Molen A, Henderson J, Cha SS, An KN, Amadio PC. Sonographic measurements of subsynovial connective tissue thickness in patients with carpal tunnel syndrome. J Ultrasound Med. 2012;31:31–36.

Vanhees M, Chikenji T, Thoreson AR, et al. The effect of time after shear injury on the subsynovial connective tissue and median nerve within the rabbit carpal tunnel. Hand (N Y). 2013;8:54–59.

Eming SA, Wynn TA, Martin P. Inflammation and metabolism in tissue repair and regeneration. Science. 2017;356:1026–1030.

Ortiz R, Gfrerer L, Hansdorfer MA, Tsui JM, Nealon KP, Austen WG Jr. The efficacy of surgical treatment for headaches in patients with prior head or neck trauma. Plast Reconstr Surg. 2020;146:381–388.

Janis JE, Dhanik A, Howard JH. Validation of the peripheral trigger point theory of migraine headaches: Single-surgeon experience using botulinum toxin and surgical decompression. Plast Reconstr Surg. 2011;128:123–131.

Gfrerer L, Raposio E, Ortiz R, Austen WG Jr. Surgical treatment of migraine headache: Back to the future. Plast Reconstr Surg. 2018;142:1036–1045.

Ducic I, Felder JM III, Janis JE. Occipital artery vasculitis not identified as a mechanism of occipital neuralgia-related chronic migraine headaches. Plast Reconstr Surg. 2011;128:908–912.

Raposio E, Caruana G. Tips for the surgical treatment of occipital nerve-triggered headaches. Eur J Plast Surg. 2017;40:177–182.

César Fernández-de-Las-Peñas ¹, Hong-You Ge, Lars Arendt-Nielsen, Maria Luz Cuadrado, Juan A Pareja The local and referred pain from myofascial trigger points in the temporalis muscle contributes to pain profile in chronic tension-type headache Clin J Pain. 2007 Nov-Dec;23(9):786-92.

César Fernández-de-Las-Peñas ¹, Hong-You Ge, Lars Arendt-Nielsen, Maria Luz Cuadrado, Juan A Pareja  Myofascial trigger points and sensitization: an updated pain model for tension-type headache Cephalalgia. 2007 May;27(5):383-93.

Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, et al. (1990) The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum 33: 160-172

Katz RS, Wolfe F, Michaud K (2006) Fibromyalgia diagnosis: a comparison of clinical, survey, and American College of Rheumatology criteria. Arthritis Rheum 54: 169-176.

Ge HY, Fernández-de-Las-Peñas C, Madeleine P, Arendt-Nielsen L (2008) Topographical mapping and mechanical pain sensitivity of myofascial trigger points in the infraspinatus muscle. Eur J Pain 12: 859-865.

Cummings M, Baldry P (2007) Regional myofascial pain: diagnosis and management. Best Pract Res ClinRheumatol 21: 367-387.

Ge HY, Fernández-de-las-Peñas C, Arendt-Nielsen L (2006) Sympathetic facilitation of hyperalgesia evoked from myofascial tender and trigger points in patients with unilateral shoulder pain. ClinNeurophysiol 117: 1545-1550.

Hocking MJ (2013) Exploring the central modulation hypothesis: do ancient memory mechanisms underlie the pathophysiology of trigger points? Curr Pain Headache Rep 17: 347.

Stecco A, Gesi M, Stecco C, Stern R (2013) Fascial components of the myofascial pain syndrome. Curr Pain Headache Rep 17: 352.

Partanen JV, Ojala TA, Arokoski JP (2010) Myofascial syndrome and pain: A neurophysiological approach. Pathophysiology 17: 19-28.

Henriksson KG, Backman E, Henriksson C, de Laval JH (1996) Chronic regional muscular pain in women with precise manipulation work. A study of pain characteristics, muscle function, and impact on daily activities. Scandanavian Journal of Rheumatology. 25: 213-223.

Findley T, Chaudhry H, Stecco A, Roman M (2012) Fascia research--a narrative review. J BodywMovTher 16: 67-75.

McCombe D, Brown T, Slavin J, Morrison WA (2001) The histochemical structure of the deep fascia and its structural response to surgery. J Hand Surg Br 26: 89-97.

Boyd-Clark LC, Briggs CA, Galea MP (2002) Muscle spindle distribution, morphology, and density in longuscolli and multifidus muscles of the cervical spine. Spine (Phila Pa 1976) 27: 694-701.

Maier A (1999) Proportions of slow myosin heavy chain-positive fibers in muscle spindles and adjoining extrafusal fascicles, and the positioning of spindles relative to these fascicles. Journal of Morphology 242: 157–65.

Klingler W, Velders M, Hoppe K, Pedro M, Schleip R (2014) Clinical relevance of fascial tissue and dysfunctions. Curr Pain Headache Rep 18: 439.

Langevin HM, Fox JR, Koptiuch C, Badger GJ, Greenan-Naumann AC, et al. (2011) Reduced thoracolumbar fascia shear strain in human chronic low back pain. BMC MusculoskeletDisord 12: 203.Purslow PP (2010) Muscle fascia and force transmission. J BodywMovTher 14: 411-417.

Trigger Point Basics 

Trigger points are local, tender, and hyperirritable spots located next to or within the skeletal muscle.  They not only produce pain locally, but also can produce referred pain to the other parts of the body. Trigger points are commonly associated with acute trauma, such as Motor Vehicle accidents, or chronic musculoskeletal conditions.

Trigger points can be active or latent.  Active trigger point has pain at rest, tender to palpation, can have referred or radiating pain to other parts of the body.  Latent trigger points usually restrict the motion or result in muscle weakness.  The patient does not have pain at rest but will complain of pain if the pressure is applied directly to trigger point location.

Traditionally trigger points are separate from tender points associated with conditions such as fibromyalgia. Trigger points are located over muscle belly. Tender points also have local tenderness, but they are not located over the belly of the muscle, do not cause referred pain, but commonly cause body hypersensitivity.

Trigger points are commonly associated with local twitch response. Local twitch response is a palpable or visible muscle contraction when the pressure on the trigger point is applied.

Causes of trigger points.

1                     acute trauma, especially caused by repetitive stress (tennis elbow, golf shoulder etc)

2                     repetitive microtrauma

3                     lack of exercise

4                     prolonged poor posture

5                     vitamin deficiency

6                     sleep deficiency

7                     repetitive occupational or recreational activity

8                     surgical scars

9                     tissues placed under tension due to surgery (after spinal or hip surgery)