23rd Annual Pain Medicine Meeting 2024

Chronic Post-Operative Pain Post-CABG

A Case of Is it Muscle, Nerve, Bone or the Heart?

Successful Treatment Of Chronic Post-operative Chest Pain After CABG With Trigger Point Injection.

Hesbon Isaboke, MD1

Alopi Patel, MD FASA2

1Department of Anesthesiology and Perioperative Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ.

CASE

• 78-year-old male with a past medical history significant for hypertension, hyperlipidemia, coronary artery disease status post-CABG x3 followed by sternal wire removal six months later, paroxysmal atrial fibrillation, and Guillain-Barre Syndrome (diagnosed at 60 years old) who presented as initial visit referral from the cardiothoracic surgeon for further evaluation of

INTRODUCTION

Trigger points are discrete, focal, hyperirritable spots located in a taut band of skeletal muscle, which are involved in muscle stiffness, tenderness, and referred pain.
These points can form from repetitive microtrauma, causing stress to the muscle fiber.
A neuroma is a non-cancerous tissue growth that can form due to swelling of nerve tissue after damage to nerves.

mid-chest pain.

The pain was initially attributed to the sternal wire from the prior procedure. The wire was subsequently removed, but the patient continued experiencing reproducible pain while golfing.
He had been using a home vibrating massage device, topical non-steroid anti-inflammatory drugs (diclofenac gel), and cold compress to the chest area, all of which only provided minimal pain relief. He reported being able to reproduce the pain with a golf-swinging motion, but the pain was not reproducible to palpation.

METHODS

On evaluation of the patient at the pain clinic, the pain distribution was consistent with a localized neuroma accompanied with myofascial tension.
A trigger point injection under ultrasound guidance was performed with local anesthesia consisting of 1mL of 1% lidocaine and 1 ml of 40mg/mL of methylprednisolone to the pectoralis major muscle along the patient's reported location.

RESULTS

The patient tolerated the procedure well without complications.
On follow-up one week later, the patient reported 100% pain

relief and had resumed his daily activities, including golfing, without pain.

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DISCUSSION

Trigger points are part of myofascial pain syndrome, which is often an overlooked diagnosis, especially when patients present with chest pain.
Postoperative neuromas are also sources of pain in post- sternotomy patients, as there may be damage to the intercostal nerves.
Pectoral muscles, serratus anterior, and scalene muscles may cause chest pain that is not reproducible on palpation during physical exam.
It is important to consider myofascial pain syndrome in patients with persistent chest pain when other common or serious differential diagnoses have been addressed.

LIMITATIONS

This is a single case study and may not be generalizable to broader patient populations.
Information is restricted to a single patient’s experience, which may vary from patient to patient.

REFERENCES

Alvarez DJ, Rockwell PG. Trigger points: diagnosis and management. Am Fam Physician. 2002 Feb 15;65(4):653-60. PMID: 11871683.
Bagcier F, Yurdakul O, Ozduran E. Three Simple Rules in

Pectoral Muscle's Trigger Point Treatment, Which May Be a

Cause of Chest Pain: Position, Palpation, and Perpendicular

Needling. J Am Board Fam Med. 2020 Nov-Dec;33(6):1031.

doi: 10.3122/jabfm.2020.06.200342. PMID: 33219086.

• Money, S. (2017). Pathophysiology of Trigger Points in

Myofascial Pain Syndrome. Journal of Pain & Palliative Care Pharmacotherapy, 31(2), 158–159. https://doi.org/10.1080/15360288.2017.1298688

23rd Annual Pain Medicine Meeting 2024

CHRONIC POST-OPERATIVE PAIN POST-CABG: A CASE OF IS IT MUSCLE, NERVE, BONE OR THE HEART?

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