INTRODUCTION: Myofascial pain is caused due to strain in the muscles and has particular sensory or motor characteristics. The trigger points are 2-5mm nodules of hypersensitive areas located within the taut band of the muscle. There is a particular area of reference zone (RZ) related to a muscle. The pain could run up or down along a RZ. Pain could range from dull ache to severe excruciating pain. Iliacus muscle helps in the extension of hip and psoas muscle is active during sitting, standing and maintaining postures. Patients with ilio-psoas myofascial pain often complain of pain in the region of back radiating to upper buttocks or in front of the hip joint. Psoas muscle originates from the transverse process of T12, L1-L5 vertebrae and inserted on the lesser trochanter of the femur. The most definite sign of trigger point would be a point of hypersensitivity, and on pressing the trigger, arousal of the pain similar to the pain complained by the patient. Sometimes the pain would also be associated with autonomic feature eg. vasovagal response, flushing, lacrimation etc. On inserting a needle in the trigger area, a twitch could be elicited. The trigger points could be active or latent. Active trigger points are points complined by the patient and latent points are the areas which the patient does not complain of, but a pressure would initiate pain in those areas. Active trigger ponts need treatment whereas latent points do not. Out of the several modalities of treatment available, we in our study have chosen injecting lignocaine 0.25% in the trigger points because this reduces the soreness at the point of needle insertion. Trigger point injections of ilio-psoas could be given using either fluoroscopy or ultrasound, and in the study we would compare these for the ease and efficacy of the block. AIMS AND OBJECTIVES: 1) To compare efficacy of the block given by the two methods by VAS scoring 2) Ease of application of the block by the operator 3) Change in DASS (Depression anxiety stress scale) scoring by two methods during follow up 4) Change in quality of life studied by Oswestry Disability Index (ODI) during follow up MATERIALS AND METHODS: After taking the patient’s consent, an i/v line would be secured and for fluoroscopy standard monitoring would be done using ECG, pulse owimeter (SPO2), non- invasive blood pressure (NIBP). Patients would be made prone, and the part would be painted using betadine and draped. FOR FLUOROSCOPY: After draping, under fluoroscope adequate positioning would be done focusing the L3 vertebrae. Taking an oblique view a 22g 5 inch needle would be inserted app. 5cms lateral to the spinous process. A gun barrel view would be obtained and the needle tip would be proceeded till about ant 1/3rd of the vertebral body in lateral view. Then dye would be injected in the muscle and confirmed by its spread along the psoas muscle belly. Patient would be given lignocaine 0.25% 10ml at the site. Then patient would be kept for 1/2 hour to monitor hemodynamic vitals. Stretching would be advised afterwards which would be done by the patient twice in a day. Tab. etoricoxib 90mg once daily would be given for five days. FOR ULTRASONOGRAPHY: Patient would be made lateral, opposite to the side where the pain is. The area would be painted and draped and using ultrasound slightly lateral from the L3 vertebrae transverse process of the L3 vertebrae would be identified. Then using a 22g 5 inch needle lignocaine 0.25% 10ml would be injected. Patients would be observed for 1/2 hr and then stretching exercises would be advised which would be done by the patient twice in a day. Tab. etoricoxib 90mg once daily would be given for five days. OBSERVATIONS: Patients would be assessed for pain using visual analog scale (VAS), for disability using Oswestry disability index (ODI), for ease of application using either fluoroscope or USG (operators subjectivity), and depression anxiety stress scale (DASS) for psychological state of the person. These observations would be done during pre-procedure, after 1st day, 1st week, 4th week, and 12th week.
STATISTICAL ANALYSIS: Assuming that patients with iliopsoas myofascial have VAS pain score of 80/100 and post triggerpoint injection by either fluoroscopy or USG would decrease pain by 40%, keeping the minimum confidence interval 95% and power of study 80% we enrolled 18 patients in either groups.
REVIEW OF LITERATURE: Studies have been done comparing the efficacy and safety of ultrasound over fluoroscopy for selectve nerve root block and transforaminal block1 proving that ultrasound also helps to identify and avoid vascular trauma. Stellate ganglion block2 or intercostal steroid injections3 has also been given with the help of ultrasound, and it has been seen that similar reduction in the vas score could be achieved as the fluoroscopy.Pudendal nerve block under USG and fluoroscopy4 proves that ultrasound is as accurate as fluoroscopically performed injections provided they are given by experienced clinicians. USG guidance for psoas compartment block has been given in the cadavers and confirmed by CT scan5. Lumbar facet joint injections6 and caudal neuroplasty7 given by ultrasound has been also confirmed by CT scan, and demonstrated significant correlation between the two. For caudal placement of injection 100% correct position was confirmed in a study done on 70 patients. On the similar grounds we would compare ilio-psoas block using ultrasound and fluoroscopy as USG could give us several benefits, such as: 1) cost effectivity 2) do the procedures on the OPD basis 3) avoid radiation exposure. 4) patient compliance is improved. 5) procedure is not delayed 6) radio-contrast dye induced side effects could be avoided.
REFERENCES
1) Jee H, Lee JH, Kim J, Park KD, Lee WY, Park Y. Ultrasound-guided selective nerve root block versus fluoroscopy-guided transforaminal 1) block for the treatment of radicular pain in the lower cervical spine: A randomized, blinded, controlled study. Skeletal Radiol. 2012 May 20. [Epub ahead of print] 2) 2) Cornelia Kean. Experts advocate ultrasound to guide stellate ganglion block anaesthesiology news march 2009 volm 35:3 3) 1 3) Shankar H, Eastwood D. Retrospective comparison of ultrasound and fluoroscopic image guidance for intercostal steroid injections. Pain Pract. 2010 Jul-Aug;10(4):312-7. Epub 2010 Mar 3. 1) 4) Bellingham GA, Bhatia A, Chan CW, Peng PW. Randomized controlled trial comparing pudendal nerve block under ultrasound and fluoroscopic guidance. Reg Anesth Pain Med. 2012 May-Jun;37(3):262-6. 5) 5) Lukas Kirchmair, Tanja Entner, Stephan Kapral, Gottfried Mitterschiffthaler. Ultrasound Guidance for the Psoas Compartment Block: An Imaging Study. Anesth Analg 2002;94:706 –10 6) 6) Greher M, Kirchmair L, Enna B, Kovacs P, Gustorff B, Kapral S, Moriggl B. Ultrasound-guided lumbar facet nerve block: accuracy of a new technique confirmed by computed tomography. Anesthesiology. 2004 Nov;101(5):1195-200. 7) 7) Chen CP, Tang SF, Hsu TC, Tsai WC, Liu HP, Chen MJ, Date E, Lew HL.Ultrasound guidance in caudal epidural needle placement. Anesthesiology. 2004 Jul;101(1):181-4.
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