Trigger points

[painfree23]

Three questions -
1) what is injected on your trigger points (steroid? Lidocaine only?)
2) How often are you doing them for a patient (3 times per year)
3) are any of you using Ultrasound to do it - if so why ?

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[RoloTomassi]

Bupivacaine, rarely ever, no

 

[Ducttape]

1. bupivacaine.
2. not a common procedure. I do maybe 3 a week.
3. yes for any thoracic injections. avoid PTX.

 

[afob100]

1. Bupivacaine 0.25% only
2. at most, monthly. usually every 2-3 months if it is helpful. low risk injection since no steroid used - so i have no problem repeating it frequently. i usually have patients combine this with dry needling from physical therapy. i probably do ~10 TPIs a week in general.
3. no reason to use ultrasound. just don't insert the needle deep in a skinny patient!

 

[deleted284725]

Tbh anyone not using ultrasound is probably mostly just doing subq fat injections.

 

[painfree23]

Tbh anyone not using ultrasound is probably mostly just doing subq fat injections.

Really?? I never use US but wondering if it’s worth the hassle. Does it bill more? Do u specifically look for something?

 

[deleted284725]

Really?? I never use US but wondering if it’s worth the hassle. Does it bill more? Do u specifically look for something?

I only really noticed after I started looking under ultrasound and I realized how deep the muscles are in most people and that I and others were almost never going deep enough when doing it blind.

 

[lobelsteve]

I only really noticed after I started looking under ultrasound and I realized how deep the muscles are in most people and that I and others were almost never going deep enough when doing it blind.

If you cannot feel the difference between fat and muscle …….

 

[Agast]

I do quite a few trigger points. Ortho patients with bad shoulders and bad necks end up with trapezius knots. It makes a satisfying crunchy feeling when I needle them and the patients are amazed when the tingling in the hand disappears.

 

[lobelsteve]

Not to mention the lack of science regarding the whole myofascial pain, trigger point pathology.

 

[ProwlerturnGas]

Not to mention the lack of science regarding the whole myofascial pain, trigger point pathology.

I have had TPI done on me. Whatever is going on, they’re amazingly effective

 

[deleted284725]

If you cannot feel the difference between fat and muscle …….

With a 25-30ga needle? Doubt. With the exception of actual trigger points. Those actually do crunch. I’ve literally watched people put the needle no more than 1 inch in and then slapped on the ultrasound and seen the targeted muscle at least half an inch deeper. As it turns out, Just putting local +/- steroids somewhere adjacent in the body makes people feel better. You’re right though, It’s probably mostly voodoo anyway.

 

[painfree23]

I do quite a few trigger points. Ortho patients with bad shoulders and bad necks end up with trapezius knots. It makes a satisfying crunchy feeling when I needle them and the patients are amazed when the tingling in the hand disappears.

Yess that crunch is amazing. Not sure what else an us would offer.

 

[pmrmd]

Not to mention the lack of science regarding the whole myofascial pain, trigger point pathology.

This. A trigger point can't even be defined or identified histologically as something to inject.

 

[deleted131481]

2% lidocaine with a fair bit of needling. Don't do it often, rarely lasts long but I have some that will ask for it monthly for a while then drop off. 80%+ in shoulders/neck.

25g 1.5in needle or 5/8in if skinny and in neck or thoracic area. Prob subq sometimes for these but not risking deeper.

Someone here mentioned myofascial plane blocks which I may break out the ultrasound to try.

 

[Doctodd]

trigger points are usually an effect of something deeper, so im usually looking for a disc or facet. I rarely do TPI's anymore....i usually send to my PT.

Bupivacaine is only used for RF now.

 

[Gnarvin]

1. 0.5% bupi, no steroid
2. At first I may do them every month but usually no more than every 2-3 months.
3. No ultrasound. I think it could be useful in the T spine especially to make sure I get in the muscle and not too deep. Haven’t started yet bc it seems like a pain and more time consuming than I want to spend on TPI.

 

[ED50]

1. .25% bupi, occasional steroid
2. If they aren't getting sustained relief then I usually don't repeat. Max q3-4 months
3. 90% + use US. I like to visualize the various muscles I am injecting. Many times it is not the most superficial muscle in a plane that is causing the problem. As a previous poster mentioned sometimes it is much deeper then you would think. Without US you are just poking and hoping

 

[lobelsteve]

And with US you are just poking and hoping.
Why steroid?

 

[Baron Samedi]

Would hate to see skin discoloration or fat atrophy from trigger point injections.

 

[Doctodd]

Would hate to see skin discoloration or fat atrophy from trigger point injections.

You should not be using more than a drop of steroid in a 5cc syringe of local anyway, so risk of those things should be minimal. I can’t recall what Travell and Simon recommended, but it’s not a joint.

 

[deleted875186]

0.25% bupi with a small amount of steroid, maybe 10 mg depo or so.

I use a 1 1/2 inch 25G, mostly doing cervical trapezius, very confident I’m in muscle, don’t know what ultrasound would add. I have used ultrasound in deeper muscles. If I’m doing lumbar paraspinal TPI or something I will hub the needle and indent the skin, but in a big patient I probably won’t reach the muscle. In these cases I don’t do TPI.

 

[Sooshi]

Lido 1% or bupi 0.25, whatever is available. Don't usually add steroid - questionable improvement in duration, but if it's a chronic patient that gets these 1-2x per year with the same formula I will add it for voodoo. Definitely US for thoracic/super thin patients. I thought it was academic extravagance until I saw how close the lungs were on a very skinny patient, which was a definite "aw HELL naw" moment in my professional development. My understanding is it doesn't bill any higher and is more cumbersome, but I want the peace of mind of knowing I didn't drop a lung for a ******* procedure I barely believe in anyway.

Anything more than 2-3x per year seems sus. Not a good treatment strategy, from what I can tell in my limited experience.

 

[ED50]

For instance, when doing cervical TP I like to visualize the trap, levator, and splenius capitus poke all three and see what happens. If no prolonged benefit then no repeat. Without US you are likely not getting all three. Plus there is lung apex and vasculature I like to see. Obvious safety benefit for thoracic spine. Don't really do much steroid but anecdotally I have seen it help (I know Steve is about to skewer me). I know the evidence doesn't support it - old habit I'm trying to break I suppose.

 

[painfree23]

US seems like such an annoying setup for such a simple procedure

 

[ED50]

It is

 

[geauxg8rs]

US seems like such an annoying setup for such a simple procedure

I hurt here. Place needle here. 50 percent of time it is identified with a sharpie marking

 

[callmeanesthesia]

I was rarely doing any steroid until I started getting denials from several payors. So I started adding 10 of kenalog.

 

[painfree23]

I was rarely doing any steroid until I started getting denials from several payors. So I started adding 10 of kenalog.

The prior auths cared what u were injecting for trigger points? Damn, these insurance companies need to use their resources better

 

[geauxg8rs]

The prior auths cared what u were injecting for trigger points? Damn, these insurance companies need to use their resources better

I had a denial from work comp once because i didn’t have a “jump sign” on exam. Work comp paid more for a 99213 than a tpi. Unreal

 

[painfree23]

I had a denial from work comp once because i didn’t have a “jump sign” on exam. Work comp paid more for a 99213 than a tpi. Unreal

Paying more for 99213 than a tpi seems reasonable …per Medicare/asipp it’s probably more for 99213 than an tpi

 

[geauxg8rs]

Paying more for 99213 than a tpi seems reasonable …per Medicare/asipp it’s probably more for 99213 than an tpi

But Why pay a doctor to review medical necessity of tpi when they pay so little?

 

[painfree23]

But Why pay a doctor to review medical necessity of tpi when they pay so little?

Agreed, that’s why I said earlier that they should direct their resources to better things

 

[Cholula]

re: Q #3, My state medicaid pays $104.91 for 76942 (US guidance), $73.66 for 76536 (diagnostic US of the posterior neck), and $34.88 for 20552 (TPI). They allow me to do a diagnostic US and US guidance for injection on same date of service without prior auth's or denials. So would I rather see a patient with medicaid for $213.45 or for $34.88?

 

[cowboydoc]

re: Q #3, My state medicaid pays $104.91 for 76942 (US guidance), $73.66 for 76536 (diagnostic US of the posterior neck), and $34.88 for 20552 (TPI). They allow me to do a diagnostic US and US guidance for injection on same date of service without prior auth's or denials. So would I rather see a patient with medicaid for $213.45 or for $34.88?

Repeated diagnostic u/s in the neck? What are you diagnosing? There seem to be much more lucrative ways to flirt with fraud.

 

[Sooshi]

Repeated diagnostic u/s in the neck? What are you diagnosing? There seem to be much more lucrative ways to flirt with fraud.

"Yep, that's a neck all right!"

 

[thiswonthurtabit]

1) what is injected on your trigger points (steroid? Lidocaine only?)
2) How often are you doing them for a patient (3 times per year)
3) are any of you using Ultrasound to do it - if so why ?

1. 0.5mL 1% lidocaine with quite a bit of needling at each location.
2. Anecdotally I've found patients have done well with a gradually increasing duration between injections so I bring them back 1 week after the first injection, how much did it help (if none or minimal no repeat injection) and how long did it last (less than ~2 days no repeat injection) then I bring them back 2 weeks later, if minimal improvement or improvement not lasting ~1 week no repeat injection, bring them back 3 weeks later etc until I'm doing it no more frequently than once a month to every other month.
3. No U/S

 

[RoloTomassi]

Repeated diagnostic u/s in the neck? What are you diagnosing? There seem to be much more lucrative ways to flirt with fraud.

😂 What's the medical necessity for diagnostic ultrasound every time? You should also look up what's required to document a diagnostic. It's essentially a detailed radiology report, and if you miss something you're probably liable so better be RMSK certified and know what you're doing.

 

[Multimodal]

re: Q #3, My state medicaid pays $104.91 for 76942 (US guidance), $73.66 for 76536 (diagnostic US of the posterior neck), and $34.88 for 20552 (TPI). They allow me to do a diagnostic US and US guidance for injection on same date of service without prior auth's or denials. So would I rather see a patient with medicaid for $213.45 or for $34.88?

I dont think you can bill both 76942 and 76536 for a single procedure. I have never used 76536 because I never do a diagnostic read of the tissue, only use US for needle guidance. its incredible that US guidance alone pays for more than the injection. wtf