Myofascial pain syndrome of thoracic spine
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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Myofascial pain syndrome (MPS) is localized pain. It is considered by some to be an offshoot of fibromyalgia.
Myofascial pain can be either acute or chronic. Myofascial patients commonly have pain in "trigger point" areas. The trigger points are the "ground zero" of the pain and pain radiates from these central points.
Substance P levels may be elevated in trigger point areas. Substance P is a chemical mediator that produces pain. Patients with MPS develop chronic overload of muscle groups, and often have poor posture as well as poor ergonomics in their work space. Most of these patients have a sedentary life-style. In addition to myofascial pain, they have headaches and neck pain.
Muscle symptoms are aggravated by cold, damp, and stress.
MPS trigger points are quite common: 54% females 45% males. Locations that are most common for trigger points are head and neck, shoulder and pelvic girdle, thoracic and lumbar spine.
The etiology of this syndrome seems to be acute overload or repeated trauma of muscles. Trigger points are activated by intense heat or cold, changing or damp weather, repetitive injury, "weekend warrior" syndrome. According to Travell and Simmons, vulnerable factors are short leg syndrome, small hemipelvis, poor posture, prolonged immobility, vitamin and mineral deficiencies, endocrine dysfunctions, intense emotional stresses, and poor work habits.
Active TPs commonly radiate to distant locations, such as neck to lateral or anterior face, lower central back to lateral buttocks, and arm muscles to hand areas. Trigger points are are 2-6 mm diameter areas, demonstrate Travell's "Jump" sign, and exhibit decreased high energy phosphates (ATP/PC) in biopsies where their glycogen values are less than normal.
Others classify myofascial pain three ways:
Local myofascial pain is suffered in one spot-perhaps in the arm after too much activity, such as playing tennis.
Regional myofascial pain affects a larger area, such as the neck, shoulder and upper back. This is seen commonly after injury or overuse.
Generalized myofascial pain, the third type of myofascial pain syndrome, is generalized. There are identifiable trigger points located in the upper shoulder, mid-thoracic spine, achilles tendon, the hip and elsewhere.
Successful treatment begins with stimulating blood flow in order to start the healing process. This requires getting the muscles to "release" so they will be receptive to treatment, and this may be done with heat, ice, ultrasound, biofeedback or trigger point massage.
Therapy should include exercise with range of motion using modest resistance with free weights or bands.
Common NSAIDs may help. Tricyclic antidepressants in low doses may also be beneficial. Newer SSRI and SNRI drugs may be better tolerated than the older tricyclic drugs. Muscle relaxants are also used.
Sympathetic blocks of the lumbar, thoracic, cervical areas have been used for the more persistent and serious problems.
A newer therapy, Botulinium toxin, 10-15 units per trigger point may be helpful. Prior to botulinium therapy, one may try lidocaine/glucocorticoid with 5 cc’s per trigger point.
The second step involves stretching the fascia of the muscles to increase their range. Physical therapists manually break up the tissue tightness with their hands.
Once they are pain-free and muscle range improves, patients begin a gradual strengthening program and work on changing postural habits, body mechanics, or other activities that might loosen up tight muscles. Biofeedback and muscle retraining/re-education may help.
Occasionally, psychological intervention is necessary to assist with controlling the stress that can exacerbate myofascial pain syndrome.
Once strength is developed, the final phase is to help the patient achieve muscle conditioning and endurance. Conditioning programs typically include walking, running and swimming, along with stretch warm-ups before they begin exercise or work in order to get healing blood flow to the muscles.
Patients work spaces may have to be modified.
Another cause of myofascial-like pain is facet syndrome.
Facet joints are small joints behind the discs which help to support the spine and allow it to move. There are 2 facet joints at each horizontal level; one on the right and one on the left of the spine. Facet joint surfaces are lined by cartilage. Each facet joint receives 2 small nerve branches from the spinal nerves, which send sensory information from the facet joint to the spinal cord and then to the brain. If the facet joint is abnormal due to arthritis, for example, the nerves become irritated.
Facet joints are susceptible to trauma and wear-and-tear changes. Trauma to facet joints such as whiplash injuries, sleeping with a twisted neck, a sudden jerk of the neck, twisting while lifting overhead, may lead to joint capsular tears, irritation of the joint surface, or distortion of the joint alignment.
Thoracic (middle back) facet syndrome may cause mid-back pain with muscle spasm, and loss of the normal thoracic spinal curve or occasionally pain encircling the rib cage. The pain is usually aggravated by spinal extension and rotation.
Treatment of facet syndrome includes conservative measures such as local heat, traction, anti-inflammatory medications (NSAIDS), muscle trigger point injections, physical therapy, manipulation, and interventional treatment such as facet joint blocks, dorsal median branch nerve blocks or denervation and prolotherapy. If conventional measures fail, facet joint injection is usually performed. If the injection produces significant but short term pain relief, denervation of the facet joint can be performed to eliminate the painful sensation from the joints and thus provide long term pain reduction (in 80% of cases).
The denervation procedure is carried out using a radio-frequency (RF) denervation (ablation) technique. A RF needle is inserted and the tip is directed to reach the nerves coming from the facet joints under X-Ray guidance. Sensory and motor tests are then performed to ensure proper placement of the RF needle on the nerve.
Complications from the procedure are rare, but most people experience transient local muscle pain and spasm (this may last 2 to 5 days or even longer). The benefit from denervation may last forever (>80% of cases) or 6 to 8 months (< 20%). Denervation may be repeated in 6 to 8 months for those whose nerves regenerate and pain returns.
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