Physician Sutter Health Pleasant Hill, California, United States
Case Diagnosis: Thoracic Paraspinal Myofascial Pain
Case Description: A 58-year-old male military veteran with a very active lifestyle including extreme sports presented to the outpatient pain management clinic with chronic axial left mid-to-low back pain for 3 years with no mechanism of injury. Physical exam demonstrated tenderness to palpation and hypertonicity at the bilateral lower thoracic paraspinal muscles between the rhomboid and erector spinae. After failing several conservative treatments, we completed an ultrasound-guided modified bilateral thoracic paraspinal trigger point injection similar to an erector spinae plane (ESP) block, given the deeper location of his pain compared to most myofascial pain. The patient returned 3.5 months after the injections with over 50% pain relief and 100% return to functional status. At that time, a second set of bilateral injections was completed, which resulted in over 70% pain relief after 3 months.
Discussions: Thoracic spine pain can affect daily activities and quality of life. Local anesthetic with or without corticosteroids can be a helpful modality for pain management of myofascial pain, and ultrasound-guidance improves accuracy and minimizes the risks associated with these procedures. While there are several ultrasound-guided injections utilized at the thoracic spine for pain management, this case discusses a novel hybrid approach of trigger point injections with technique similar to an ESP nerve block. The proposed primary mechanism of ESP nerve blocks is via physical spread and diffusion to neural structures in the fascial plane deep to erector spinae muscles and adjacent tissue compartments.
Conclusions: This is the first reported case utilizing a novel hybrid approach of trigger point injections utilizing a technique similar to an ESP nerve block. This treatment was effective for this patient after failing several conservative treatments and may be useful for other patients with myofascial pain of the thoracic spine.
