Trigger Point Injection Equipment and Technique

Essential Equipment and Medications

• The British Medical Journal recommends using a 22-25 gauge needle for trigger point injections, with a length of 1.5-3.5 inches depending on patient body habitus 1
• A 22-25 gauge needle is the standard size for trigger point injections, according to the Alzheimer's and Dementia journal 2
• The British Medical Journal recommends using 0.5% lidocaine as the local anesthetic for trigger point injections 1
• The Journal of Neurosurgery suggests using 0.25-0.5% bupivacaine as an alternative local anesthetic for longer duration of action 3
• The British Medical Journal guidelines specifically recommend against using glucocorticosteroids in trigger point injections 1

Needle Selection and Technique

• For superficial paraspinal trigger points, a 22-25 gauge, 1.5 inch needle is recommended, according to the Alzheimer's and Dementia journal 2
• For deep quadratus lumborum or multifidus trigger points, a 22-25 gauge, 2.5-3.5 inch needle is recommended, according to the Alzheimer's and Dementia journal 2
• For obese patients, a 3.5 inch needle may be necessary to reach deep muscle layers, according to the Alzheimer's and Dementia journal 2

Medication Dosing and Administration

• The typical volume per trigger point is 0.5-2 mL, according to the Journal of Neurosurgery 3

Trigger Point Injection Guidelines for Lumbar Back Pain

Primary Injection Sites and Techniques

• The American Society of Pain and Neuroscience provides a strong recommendation in favor of trigger point injections, irrespective of medication type, for chronic back pain 4
• The 2021 American College of Occupational and Environmental Medicine recommends trigger point injections with local anesthetic but specifically recommends against glucocorticosteroids 4

Medication Selection and Injection Technique

• Local anesthetic alone (0.5% lidocaine) is as effective as local anesthetic plus steroid for trigger point injections 5

Clinical Algorithm for Site Selection and Important Clinical Caveats

• Do not perform trigger point injections in patients with untreated radiculopathy, as epidural steroid injections are more appropriate for radicular symptoms 4, 6
• Avoid repeated injections without documented quantifiable improvement (≥50% pain reduction for ≥2 months) 7
• Do not repeat injections more frequently than every 2 months if therapeutic effect is achieved 7
• Limit to 6 total injection sites per session (up to 3 levels bilaterally) to avoid excessive medication exposure and allow assessment of response 6