The Great Auricular Nerve Trigger Site: Anatomy, Compression Point Topography, and Treatment Options for Headache Pain.

BACKGROUND: Peripheral nerve decompression surgery can effectively address headache pain caused by compression of peripheral nerves of the head and neck. Despite decompression of known trigger sites, there are a subset of patients with trigger sites centered over the postauricular area coursing. The authors hypothesize that these patients experience primary or residual pain caused by compression of the great auricular nerve. METHODS: Anatomical dissections were carried out on 16 formalin-fixed cadaveric heads. Possible points of compression along fascia, muscle, and parotid gland were identified. Ultrasound technology was used to confirm these anatomical findings in a living volunteer. RESULTS: The authors' findings demonstrate that the possible points of compression for the great auricular nerve are at Erb's point (point 1), at the anterior border of the sternocleidomastoid muscle in the dense connective tissue before entry into the parotid gland (point 2), and within its intraparotid course (point 3). The mean topographic measurements were as follows: Erb's point to the mastoid process at 7.32 cm/7.35 (right/left), Erb's point to the angle of the mandible at 6.04 cm/5.89 cm (right/left), and the posterior aspect of the sternocleidomastoid muscle to the mastoid process at 3.88 cm/4.43 cm (right/left). All three possible points of compression could be identified using ultrasound. CONCLUSIONS: This study identified three possible points of compression of the great auricular nerve that could be decompressed with peripheral nerve decompression surgery: Erb's point (point 1), at the anterior border of the sternocleidomastoid muscle (point 2), and within its intraparotid course (point 3).

Migraine Surgery at the Frontal Trigger Site: An Analysis of Intraoperative Anatomy.

BACKGROUND: The development of migraine headaches may involve the entrapment of peripheral craniofacial nerves at specific sites. Cadaveric studies in the general population have confirmed potential compression points of the supraorbital and supratrochlear nerves at the frontal trigger site. The authors' aim was to describe the intraoperative anatomy of the supraorbital and supratrochlear nerves at the level of the supraorbital bony rim in patients undergoing frontal migraine surgery and to investigate associated pain. METHODS: PATIENTS: scheduled for frontal-site surgery were enrolled prospectively. The senior author (W.G.A.) evaluated intraoperative anatomy and recorded variables using a detailed form and operative report. The resulting data were analyzed. RESULTS: One hundred eighteen sites among 61 patients were included. The supraorbital nerve traversed a notch in 49 percent, a foramen in 41 percent, a notch plus a foramen in 9.3 percent, and neither a notch nor a foramen in one site. The senior author noted macroscopic nerve compression at 74 percent of sites. Reasons included a tight foramen in 24 percent, a notch with a tight band in 34 percent, and supraorbital and supratrochlear nerves emerging by means of the same notch in 7.6 percent or by means of the same foramen in 4.2 percent. Preoperative pain at a site was significantly associated with nerve compression by a foramen. CONCLUSIONS: The intraoperative anatomy and cause of nerve compression at the frontal trigger site vary greatly among patients. The authors report a supraorbital nerve foramen prevalence of 50.3 percent, which is greater than in previous cadaver studies of the general population. Lastly, the presence of pain at a specific site is associated with macroscopic nerve compression.

[Mapping of motor-points in the flexor muscles of the arm for the optimization of botulinum toxin injections in treatment of spasticity]. / Kartirovanie motornykh tochek myshts-sgibatelei ruki dlia optimizatsii vvedeniia botulinicheskogo toksina pri lechenii spastichnosti.

AIM: To study the location and verification of motor points (MP) of the upper limbs for targeting botulinum toxin (BT) type A injections in the treatment of spasticity. MATERIAL AND METHODS: Twenty healthy people were examined. Using electromyography a complete study of the muscles of the upper limbs was conducted. RESULTS: Anatomical localization of MP was performed. The location of MP is identical and does not depend on sex, age and the dominant limb. Tables and maps of MP locations are presented. CONCLUSION: MP in the flexor muscles of the arm were identified. A surface map with MP location was created. This data may improve the clinical efficacy and feasibility of MP targeting, when injecting BT in spasticity.

Anatomical Basis of the Myofascial Trigger Points of the Gluteus Maximus Muscle.

Myofascial pain syndrome is characterized by pain and limited range of motion in joints and caused by muscular contracture related to dysfunctional motor end plates and myofascial trigger points (MTrPs). We aimed to observe the anatomical correlation between the clinically described MTrPs and the entry point of the branches of the inferior gluteal nerve into the gluteus maximus muscle. We dissected twenty gluteus maximus muscles from 10 human adult cadavers (5 males and 5 females). We measured the muscles and compiled the distribution of the nerve branches into each of the quadrants of the muscle. Statistical analysis was performed by using Student's t-test and Kruskal-Wallis tests. Although no difference was observed either for muscle measurements or for distribution of nerve branching among the subjects, the topography of MTrPs matched the anatomical location of the entry points into the muscle. Thus, anatomical substract of the MTrPs may be useful for a better understanding of the physiopathology of these disorders and provide basis for their surgical and clinical treatment.

Trigger points: an anatomical substratum.

This study aimed to bring the trapezius muscle knowledge of the locations where the accessory nerve branches enter the muscle belly to reach the motor endplates and find myofascial trigger points (MTrPs). Although anatomoclinical correlations represent a major feature of MTrP, no previous reports describing the distribution of the accessory nerve branches and their anatomical relationship with MTrP are found in the literature. Both trapezius muscles from twelve adult cadavers were carefully dissected by the authors (anatomy professors and medical graduate students) to observe the exact point where the branches of the spinal accessory nerve entered the muscle belly. Dissection was performed through stratigraphic layers to preserve the motor innervation of the trapezius muscle, which is located deep in the muscle. Seven points are described, four of which are motor points: in all cases, these locations corresponded to clinically described MTrPs. The four points were common in these twelve cadavers. This type of clinical correlation between spinal accessory nerve branching and MTrP is useful to achieve a better understanding of the anatomical correlation of MTrP and the physiopathology of these disorders and may provide a scientific basis for their treatment, rendering useful additional information to therapists to achieve better diagnoses and improve therapeutic approaches.

Puntos gatillo miofasciales en el músculo glúteo medio en pacientes con lumbalgia mecánica: análisis topográfico / Myofascial trigger points in the gluteus medius muscle in patients with mechanical low back pain: Topographic analysis

Introducción: El dolor lumbar de causa mecánica es una patología prevalente, siendo una de las causas asociadas el dolor en la zona glútea. El síndrome de dolor miofascial es uno de los cuadros dolorosos crónicos más frecuente del sistema músculo-esquelético y se encuentra representado por los puntos gatillo miofasciales (PGM). El objetivo de nuestro estudio fue determinar qué zona del músculo glúteo medio se encuentra más afectada por la presencia de PGM activos en pacientes con dolor lumbar inespecífico de origen mecánico. Método: Se realizó una serie de casos en la que se exploró a 13 pacientes con dolor lumbar de origen mecánico. Se evaluó la presencia de PGM activos y los umbrales de dolor a la presión (UDP) sobre el músculo glúteo medio. Se elaboró un mapa topográfico del músculo glúteo medio mediante 9 puntos para determinar la zona anatómica más afectada. Resultados: La intensidad media del dolor fue de 6,4 ± 1,7 cm y el tiempo medio de duración del dolor fue de 6,2 ± 4,1 años. Cada paciente con dolor lumbar mostró una media ± DE de PGM activos sobre el músculo glúteo medio de 5,6 ± 1,3. No se encontró asociación alguna entre el número de PGM activos sobre el glúteo medio y el tiempo de duración de los síntomas (r = 0,191; p = 0,622) o la intensidad del dolor (r = 0,026; p = 0,932). Los PGM activos sobre el glúteo medio se encontraron más frecuentemente en las fibras más posteriores y superiores del músculo (puntos 1-2-4), aunque las fibras antero-superiores (punto 3) y medias (punto 5) también albergaron gran cantidad de PGM activos. No existieron diferencias significativas en los UDP entre los distintos puntos. Conclusiones: El presente estudio encontró que las fibras posteriores y superiores del músculo glúteo medio se encuentran más afectadas por PGM activos en pacientes con dolor lumbar de origen mecánico

Introduction: Mechanical low back pain is one of the most prevalent pain conditions and is associated with pain in the gluteal region. Myofascial pain syndrome is a common condition associated with musculoskeletal pain which is mainly represented by myofascial trigger points (MTrPs). The aim of this study was to determine which area of the gluteus medius muscle is the most affected by active MTrPs in patients with low back pain. Methods: A case series that included 13 patients with mechanical low back pain was performed. Active MTrPs and pressure pain thresholds (PPT) were assessed on the gluteus medius muscle. A topographical map of the gluteus medius muscle was elaborated using 9 points around the muscle to determine the most affected anatomical zone. Results: The intensity of low back pain was 6.4 ± 1.7 cm and mean time with pain was 6.2 ± 4.1 years. Each low back pain patient exhibited a mean ± SD number of active MTrPs of 5.6 ± 1.3 on the gluteus medius. No association was found between the number of active MTrPs on the gluteus medius and the duration of pain history (r = 0-191; P = 0.622) or the intensity of pain (r = 0.026; P = 0.932). Active MTrPs within the gluteus medius muscle were most frequently found in the posterior and superior fibers of the muscle (points 1-2-4). Active TrPs were also found in the anterior and superior (point 3) and medium fibers (point 5) of the muscle. No significant differences were found on PPT between points. Conclusions: In the current study, it was found that the posterior and superior fibers of the gluteus medius muscle were the most affected by active MTrPs in patients with mechanical low back pain

Fascial components of the myofascial pain syndrome.

Myofascial pain syndrome (MPS) is described as the muscle, sensory, motor, and autonomic nervous system symptoms caused by stimulation of myofascial trigger points (MTP). The participation of fascia in this syndrome has often been neglected. Several manual and physical approaches have been proposed to improve myofascial function after traumatic injuries, but the processes that induce pathological modifications of myofascial tissue after trauma remain unclear. Alterations in collagen fiber composition, in fibroblasts or in extracellular matrix composition have been postulated. We summarize here recent developments in the biology of fascia, and in particular, its associated hyaluronan (HA)-rich matrix that address the issue of MPS.

[Trigger point therapy for myofascial pain in cancer patients (second report) analysis results of special use-results surveillance by neovitacain® injection].

Our first report mentioned the analysis results of the safety and efficacy of trigger point (TP) therapy by Neovitacain® injection (NV) in the daily clinical treatment of myofascial pain in cancer patients. This time, we report additional considerations regarding the following points; (1) Injection sites: they were concentrated on both sides of the spine, indicating that TPs could be easily formed on the points and near them to support the body's weight when patients were supine. (2) Correlation between VAS and FS: VAS and FS were positively correlated in every measurement period. (3) Patient satisfaction: many patients made several comments expressing feelings of satisfaction from this treatment. The comments were considered to reflect the patients' candid feelings. Therefore, all comments were classified according to the degree of patients' feeling of satisfaction. It may be possible to obtain much higher patient satisfaction by hearing out the voice of the patients. Judging from this study, TP therapy by NV for myofascial pain in cancer patients relieved the total pain of cancer patients. TP therapy has potential for obtaining high patient satisfaction.