Randomized trial of trigger point injection for renal colic

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1 Blackwell Science, LtdOxford, UK IJU International Journal of Urology Blackwell Science Asia Pty Ltd 99September Trigger point injection for renal colic M Iguchi et al /j x Original Article475479BEES SGML International Journal of Urology (2002) 9, Original Article Randomized trial of trigger point injection for renal colic MASANORI IGUCHI, 1 YOSHINARI KATOH, 1 HIROYUKI KOIKE, 1 TAIJI HAYASHI 1 AND MASATO NAKAMURA 2 Departments of 1 Urology and 2 Anesthesiology, Kaizuka City Hospital, Osaka, Japan Abstract Key words Background: Many drugs have been utilized for the treatment of renal colic, but to date no drugs that relieve pain quickly and completely have been developed. Thus, we conducted a prospective trial to evaluate the effects of trigger point injection on renal colic. In this study, we used a local injection of lidocaine to the trigger point of patients experiencing renal colic, and evaluated the efficacy in patients using the visual analog scale. Methods: Sixty patients with renal colic were enrolled in this study and divided into two groups by a simple randomization: (i) the butylscopolamine group (n = 30, intravenous injection of butylscopolamine bromide and sulpyrine); and (ii) the lidocaine group (n = 30, local anesthesia to the trigger point with lidocaine). Results: Renal colic had disappeared completely at the end of the trigger point injection in 15/30 patients and the average time required to produce a 50% improvement in symptoms was 9 min in all patients in the group. In the lidocaine group, only one patient needed an additional anodyne treatment after 60 min and none of the 29 patients whose pain disappeared within 60 min needed further anodyne treatment within 24 h. These results were all significantly superior to those of the conventional treatment. No side-effects and complications were observed. Conclusion: Trigger point injection, in our experience, is an easy, safe and effective method for the amelioration of renal colic. It was significantly superior to the combination of intravenous butylscopolamine and sulpyrine. renal colic, trigger point, trigger point injection, visual analog scale. Introduction Renal calculus is a common disorder, and renal colic is frequently observed in outpatient clinics. Because renal colic pain is severe, the first priority of treatment is rapid and complete relief of pain. The conventional treatment of severe renal colic has been the parenteral administration of narcotic analgesics or non-steroidal anti-inflammatory drugs (NSAIDs) 1,2 or intravenous injection of combination drugs (antispasmodic and anti-inflammatory agents), which is commonly used in Japan. Although the anodyne effect of these drugs is well recognized from clinical experience, the immediate effects are slow, and more rapid effects are desired in clinical practice. Correspondence: Masanori Iguchi MD PhD, Department of Urology, Kaizuka City Hospital, , Hori, Kaizuka City, Osaka , Japan. iguchi@skyblue.ocn.ne.jp Received 8 November 2001; accepted 11 March We previously observed that the patients with renal colic have a tender point (trigger point) in the ipsilateral back, and that injection of local anesthetic at this point immediately resolved the pain. Thus, we conducted a prospective trial to evaluate the effects of trigger point injection on renal colic. In this study, we used local injection of lidocaine to the trigger point of patients experiencing renal colic, and compared the analgesic and immediate effects to those of intravenous injection of both butylscopolamine bromide and sulpyrine, using a visual analog scale (VAS) for quantifying pain. 3 5 Methods Protocol This study started in January Patients with renal colic who consulted our outpatient clinic were enrolled in this study. These patients were divided into two

2 476 M Iguchi et al. groups by a simple randomization: (i) the butylscopolamine group (intravenous injection of butylscopolamine bromide of 40 mg + sulpyrine 500 mg + 5% glucose 20 ml); and (ii) the lidocaine group (local anesthesia to the trigger point with 1% lidocaine of ml). Patients who had received some previous treatments for renal colic in other clinics, who had allergy to sulpyrine and/or lidocaine, and who mainly complained of lower abdominal pain, which is usually a sign of calculi in the lower ureter, were excluded from this study. The diagnosis of ureteral stone was confirmed by urgent plain X-ray film, intravenous urography, renal ultrasound sonography and red cells found on routine urinalysis. All stones causing renal colic existed in the upper or middle ureter, and no forniceal ruptures were observed in any patients. The objective numbers were decided as 30 patients for each group from the results of preliminary study. Among 17 patients with renal colic who consulted our outpatient department, 60 patients, who gave their informed consent, participated in this study (the butylscopolamine group: 30 patients, the lidocaine group: 30 patients) and 57 patients were excluded from this study (Fig. 1). Fig. 1 Trial profile. Administration of local anesthetic to the trigger point In the prone position, the trigger point is ascertained using gentle pressure from the end of a metal sound or the end of a ballpoint pen applied at regular 1 cm intervals in the triangle bounded by the costal margin, the vertebral spine, and the iliac crest (Figs 2a,2b). The patient is observed closely during the palpation because pressure on the markedly tender trigger point usually Fig. 2 The trigger point for renal colic is systematically searched for at regular intervals of 1 cm squares at the ipsilateral back area.

3 Trigger point injection for renal colic 477 Table 1 Patient profiles of both groups Butylscopolamine group Lidocaine group No. patients Age 43.3 ± 14.8* 41.3 ± 12.4 NS Male : Female 23 : 7 21 : 9 NS Stone side (rt : lt) 15 : : 17 NS Stone size (mm) 4.1 ± ± 2.1 NS Stone condition (FS : RS) 16 : : 14 NS *Mean ± SD. FS, first stone; lt, left; NS, not significant (chi-square test or Student s t-test); RS, recurrent stone; rt, right. Fig. 3 After disinfection with an antiseptic solution, 2 3 ml of lidocaine is injected intracutaneously and forms a wheal of about 3 cm in diameter. Fig. 4 A long needle is inserted into the deep position of the psoas, and 5 10 ml of lidocaine is injected. causes the patient to jump, wince, or cry out. This procedure only takes a few minutes with a small amount of experience. After disinfection with an antiseptic solution, 2 3 ml of 1% lidocaine is injected intracutaneously and forms a wheal of about 3 cm in diameter (Fig. 3). In addition, a long needle (23-gauge 6 cm) is inserted into the deep portion of the psoas (in practice, about 4 5 cm depth in average Japanese men and about 3 4 cm depth in average Japanese women), and 5 10 ml of 1% lidocaine is injected (Fig. 4). The purpose of this study was to compare both the anodyne and immediate effect, and persistent effect between the two treatments. Pain was evaluated by the patient according to a VAS scale consisting of a straight line 10 cm long and marked in cm intervals. Point 0 was regarded as no pain and point 10 as the most excruciating pain. Assessments were made before and after treatment every 10 min until 60 min after the treatment. The time to pain relief was measured from the time of drug intravenous injection in the butylscopolamine group, and from the time when the search for the trigger point was began in the lidocaine group. First, the immediate effects of the treatment were compared with regard to the decrease in VAS score at each 10 min interval after treatment in each group. Second, the time required to produce a 50% improvement in VAS score after treatment and the frequency of an additional analgesic treatment after 60 min were compared in each group. Third, persistent effects of the treatment were compared with regard to the frequency of an additional analgesic treatment within the following 24 h in each group. Blood pressure and heart rate were measured at the same time. If the pain control was insufficient, immediate treatment with an intramuscular injection of pentazocine was performed at the request of the patient. Student s t-test and the chi-square test were utilized for statistical analysis. Results Profiles of the two groups are shown in Table 1. There was no significant difference in age, gender, stone side, stone size and stone condition between the two groups.

4 478 M Iguchi et al. Table 2 Visual analog scale score and complete response rate at each 10 min interval Before treatment After treatment 10 min 20 min 30 min 40 min 50 min 60 min No response Butylscopolamine group VAS score 8.44 ± ± ± ± ± ± ± 1.98 Complete responders 1/30 3/30 9/30 17/30 20/30 22/30 8/30 Lidocaine group VAS score 9.00 ± ± 2.75* 1.17 ± 1.95* 0.63 ± 1.38** 0.30 ± ± ± 0.55 Complete responders 15/30 20/30 23/30 27/30 28/30 29/30 1/30 *P < 0.01; **P < 0.05 compared to the butylscopolamine group. Although the VAS score before treatment did not differ between the two groups, the VAS score in the butylscopolamine group decreased by only 2.65 points at 10 min after treatment, and that in the lidocaine group was decreased by 6.84 points at the same point in time (P < 0.01). This significant difference continued until 30 min after treatment (Table 2). The time required to produce a 50% improvement in symptoms was 15.3 ± 7.8 min in the butylscopolamine group, and 9.0 ± 7.5 min in the lidocaine group (P < 0.01). Colic disappeared completely within 10 min in only one patient in the butylscopolamine group, whose VAS score was 5.1 points before treatment. On the other hand, 15 patients in the lidocaine group, whose VAS score ranged from 7.5 to 10.0 points (mean ± SD: 9.12 ± 0.95 points), experienced immediate relief of pain after the trigger point injection (P < 0.01) (Table 2). Eight patients in the butylscopolamine group and one patient in the lidocaine group needed another anodyne treatment (intramuscular injection of pentazocine) after 60 min (P < 0.05) (Table 2). Although 5/22 patients whose renal colic disappeared within 60 min in the butylscopolamine group needed further anodyne treatment within 24 h, none of the 29 patients whose pain disappeared within 60 min in the lidocaine group required further anodyne treatment within 24 h (P < 0.01). Vital signs of the patients in both groups did not change during the 60 min of treatment and there were no side-effects or complications in either group within 24 h. The 27 and 28 stones causing renal colic in the butylscopolamine group and the lidocaine group respectively were spontaneously discharged later, and the other stones were subjected to extracorporeal shock wave lithotripsy. Discussion Since renal colic pain induced by ureteral stones is severe, immediate and strong, anodyne treatment is necessary. Opiates have been the mainstay of therapy for renal colic for many years and relieve pain through central action at opiate receptors. Although opiates have a strong anodyne effect, they have a potential to be abused, may cause excessive sedation or other central effects, and may lead to gastrointestinal side-effects. 6 Recently, the effectiveness of NSAIDs for renal colic was reported, and NSAIDs were found to be as effective as narcotic analgesics. 1,2 Pain due to ureteral obstruction is a result of increased intrapelvic and ureteric pressure secondary to the obstructing stimulus. The rise in renal blood flow (RBF) that follows obstruction leads to increased urine output, further increasing the intrapelvic and ureteral pressure. Since prostaglandins contribute to the rise in RBF and contract smooth muscle, they contribute to the pain of colic at several points. 7 Since NSAIDs are potent inhibitors of cyclooxygenase, their mechanism of pain relief differs from that of narcotic analgesics; NSAIDs can reduce pain both locally and through a central mechanism by inhibiting prostaglandin synthesis. 8 However, in addition to directly affecting the pain pathway, NSAIDs may decrease RBF and ureteral pressure in the situation of acute ureteral obstruction. 7 Although beneficial for pain management, such effects may also be detrimental to renal function in the affected kidney. In this study, we evaluated the anodyne and immediate effects of intravenous injection of both butylscopolamine bromide and sulpyrine as a control, but we did not compare those effects of trigger point injection to those of NSAIDs. The reasons are that (i) intravenous NSAIDs are not available in this country, and (ii) in our clinical experience, the immediate effect of intravenous injection of both butylscopolamine bromide and sulpyrine, which are largely used as combination drugs in Japan, is superior to that of NSAID suppositories. Flannigan et al. reported the effect of indomethacin suppositories in the relief of ureteric colic, and that the average time required to produce a 50% improvement in symptoms was 26.3 min using a method similar to that

5 Trigger point injection for renal colic 479 used in our evaluation (VAS). 9 However, the average time required to produce a 50% improvement in symptoms in the butylscopolamine group was 15.3 min, which was superior to that of indomethacin suppositories. Although these combination drugs have a rapid effect for relief of renal colic, we think the main anodyne effect may be due to the effect of the sulpyrine injection, and that the use of these combination drugs may be avoided in the future because of their pharmacological invalidity and the side-effects reported in the literature. 1 In the present study, we utilized local anesthesia at the trigger point of renal colic. Trigger point injection is frequently utilized for pain control of myofascicular pain syndrome and chronic visceral pain, and the anodyne effect is strong and immediate. 10,11 Trigger points are considered to be points on the body surface that induce referred pain at the reference zone, and the trigger point for renal colic pain usually exists at the ipsilateral back area. Although there are no reports on the use of trigger point injection for the relief of renal colic in the literature, in our clinical experience pressure or intracutaneous saline injection at the trigger point decreased the pain, and intracutaneous anesthetic injection at the trigger point immediately stopped the pain. In this study, renal colic had disappeared completely by the end of the trigger point injection in half of our patients and the relief time was prolonged to over 24 h in almost all cases, and no side-effects or complications were observed. Fine et al. reported that all improvements afforded by myofascial trigger point injection were significantly reversed with intravenous naloxone compared to an intravenous placebo, and this suggested that an endogenous opioid system acted as a mediator for the decreased pain and improved physical findings following injection to myofascial trigger points with a local anesthetic. 11 Although the mechanism of this phenomenon has not been elucidated completely, the inactivation of the cycle of reflexes is thought to play a major role. Eble reported that reflex contraction of the paravertebral muscles in rabbits appeared with distension of the renal pelvis and compression of the ureter and discussed somatic muscle contraction responses to visceral stimuli. 12 If the reverse interchange, the visceral response to somatic stimuli, also exists, then the response gained from trigger point injection may be due to this mechanism. Trigger points are small-circumscribed areas of focal hyperirritability. They may be found almost anywhere in the body, both in superficial and deep muscle. 13 In order to apply the injection technique successfully, it is necessary to determine the exact location of the trigger point. Locating the point takes only a few minutes with a small amount of experience, and is relatively easy to confirm with the patients. Trigger point injection, in our experience, is an easy, safe and effective method for the amelioration of renal colic and in this study trigger point injection of lidocaine was significantly superior to the combination of intravenous butylscopolamine and sulpyrine. References 1 Laecke EV, Oosterlinck W. Physiopathology of renal colic and the therapeutic consequences. Act Urol. Belg. 1994; 62: Labrecque M, Dostaler L, Rousselle R, Nguyen T, Poirier S. Efficacy of nonsteroidal anti-inflammatory drugs in the treatment of acute renal colic. A metaanalysis. Arch. Intern. Med. 1994; 154: Huskisson E. Measurement of pain. Lancet II 1974, Maxwell C. Sensitivity and accuracy of the visual analog scale: a psycho-physical classroom experiment. Br. J. Cli. Pharmacol. 1978; 6: Revill S, Robinson J, Rosen M, Hogg M. The reliability of linear analogue score for evaluating pain. Anaesthesia 1976; 31: Jaffe J, Martin W. Opiod analgesics and antagonists. In: Gilman A, Rall T, Nies A, Taylor P (eds). Goodman and Gilman s Pharmacological Basis of Therapeutics, 8th edn. Pergamon Press, New York, 1990: Perlmutter AL, Miller Trimble L, Marion D, Vaughan E, Felsen D. Toradol, an NSAID used for renal colic, decreases renal perfusion and ureteral pressure in caine model of unilateral ureteral obstruction. J. Urol. 1993; 149: Ferreira S. Prostaglandins, pain and inflammation. Agents Actions 1986; 19 (Suppl.): Flannigan G, Clifford R, Carver R, Yule A, Madden N, Towler J. Indomethacin an alternative to pethidine in ureteric colic. Br. J. Urol. 1983; 55: Melzack R, Stillwell D, Fox E. Trigger points and acupuncture points for pain: correlations and implications. Pain 1977; 3: Fine P, Milano R, Hare B. The effects of myofascial trigger point injections are naloxone reversible. Pain 1988; 32: Eble JN. Patterns of response of the paravertebral musculature to visceral stimuli. Am. J. Physiol. 1960; 198: Wyant G. Chronic pain syndromes and their treatment. II: Trigger points. Can. Anaesth. Soc. J. 1979; 26: