OBSERVATION Subcutaneous Trigger Point Causing Radiating Postsurgical Pain Ali Hendi, MD; Peter T. Dorsher, MD; Thomas D. Rizzo Jr, MD; Lawrence E. Gibson, MD Background: The immediate onset of severe postop- ate postoperative period with referred (distant) pain ex- erative pain, especially pain radiating distant from the in- tending down the ipsilateral arm that was caused by a cision site, is uncommon after dermatologic surgery. thoracic subcutaneous trigger point. Observation: A 37-year-old woman undergoing exci- Conclusion: Surgeons and pain management specialists sion of a nevus from the left side of her midback had an should be aware of this potential cause of immediate post- exquisitely tender spot along the incision lines. This ten- operative pain to prevent unnecessary medical or surgical der spot was hard to anesthetize and was clinically vis- interventions in the postoperative period. ible, after excision of the nevus, as a fibrous bundle in the subcutaneous plane. She presented in the immedi- Arch Dermatol. 2009;145(1):52-54 HEN A PATIENT HAS gins was planned. Local anesthesia con- severe incisional sisted of lidocaine, 1% (Xylocaine), with pain after a derma- 1:100 000 epinephrine buffered with so- tologic surgical pro- dium bicarbonate. The buffered anesthetic cedure, several pos- agent was prepared by adding 3 mL of so- Wsibilities should be considered. Immediate dium bicarbonate to 27 mL of lidocaine. postoperative pain (0-24 hours) may be a While receiving the injections of local an- sign of an acute hematoma, which is a sur- esthetic, the patient complained of a par- gical emergency. Alternatively, inci- ticularly tender focal site superior to the ne- sional pain in the immediate postopera- vus. A total of 6 mL of buffered lidocaine tive period may be a normal sequela of the with epinephrine was used preoperatively. procedure. Postoperative edema may cause Intraoperatively, the patient complained of painful distention of the local tissues. De- sharp pain at the same site superior to the layed postoperative pain (5-7 days) is of- nevus, which necessitated injection of an ad- ten a sign of infection, which is associ- ditional 2 mL of anesthetic agent into this ated with marked redness, drainage, area before the nevus could be excised. The warmth, fever, or a combination of these surrounding skin was undermined to re- clinical signs. We describe a patient with move tension from the wound margins. unusually severe intraoperative and post- Electrocautery (electrodesiccation) was used operative pain attributable to a subcuta- to obtain hemostasis. Application of the elec- neous thoracic trigger point that was noted trosurgical needle to the same tender site su- during excision of a nevus. The pain was perior to the nevus caused severe pain de- associated with marked incisional ery- spite the anesthetic injections. On close thema, hyperesthesia, and referred (dis- inspection of this area, a white fibrous tant) pain extending down the ipsilateral bundle of tissue measuring approximately Author Affiliations: arm to the hand. 0.5 to 1.0 cm was visualized in the deep sub- Department of Dermatology cutaneous fat. An additional 1 mL of local (Dr Hendi) and Department of anesthetic was injected into this area. The Physical Medicine and REPORT OF A CASE patient again complained of severe pain with Rehabilitation (Drs Dorsher and the injection. The defect was then closed in Rizzo), Mayo Clinic, A thin 37-year-old woman was referred for a layered manner using buried 3-0 polygly- Jacksonville, Florida; and Department of Dermatology excision of an atypical nevus on her left mid- colic acid (Vicryl) sutures and superficial 5-0 (Dr Gibson), Mayo Clinic, back. On physical examination, the nevus fast-absorbing gut sutures. The deep fascia Rochester, Minnesota. Dr Hendi was 1.0ϫ0.8 cm and was located on the left and underlying musculature were not vio- is now in private practice in midback below the scapula. An obliquely lated at any time during the surgical Chevy Chase, Maryland. oriented elliptical excision with 3-mm mar- procedure. (REPRINTED) ARCH DERMATOL/ VOL 145 (NO. 1), JAN 2009 WWW.ARCHDERMATOL.COM 52 ©2009 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 Figure 2. Photograph taken on the first postoperative day shows the wound medial to the left scapula. Note severe peri-incisional erythema. with pain radiation above and below the incision site on the left side and into her left upper limb. On examina- tion, she was in moderate distress due to the pain and demonstrated diffuse co-contraction of her muscles (el- evation and protraction of both shoulders, clenching of her toes, and slow deliberate movements accompanied by reports of pain). Findings from the neurologic exami- nation were normal, as was passive range of motion, once the patient began to relax. Myofascial pain syndrome was diagnosed, and ace- taminophen with codeine and cyclobenzaprine hydro- chloride were prescribed. The analgesic was provided for the severe postoperative pain, and cyclobenzaprine was added as a sedating muscle relaxant, given the muscle co-contraction and psychological distress noted on ex- amination. A transcutaneous electrical nerve stimula- tion (TENS) unit for pain relief was recommended be- Figure 1. Myofascial referred pain pattern of the latissimus dorsi muscle. cause the patient was familiar with this modality and had Reprinted with permission from the Mayo Foundation for Medical Education a unit available for her use. and Research. She was seen 1 week later and referred for physical therapy consisting of biofeedback, desensitizing mas- The patient returned the next day and reported se- sage, active/assisted range of motion for the shoulder and vere pain at the left thoracic surgical site that radiated thoracic spine to decrease the pain, and aerobic exer- from the low thoracic and upper lumbar regions near the cise. She was also referred for a trial of acupuncture. She surgical site to her left upper back and scapular region was seen for 5 sessions in physical therapy for 2 weeks and intermittently down her left arm to her hand (radi- and experienced marked (Ͼ80%) improvement in her ating pain pattern is shown in Figure 1). She had not pain symptoms as well as improved tolerance to mas- been able to sleep the night after surgery because of her sage and exercise. She was seen by a physiatrist trained severe pain. The postoperative surgical bandage was re- in acupuncture (P.T.D.) approximately 6 weeks after sur- moved. There was marked erythema superior to the clo- gery. The physiatrist documented more than 80% im- sure; yet inferior to the incision, there was at most mild provement in her pain as well as continued normal neu- erythema (Figure 2). The area superior to the surgical rologic examination findings and only minimal tenderness incision was exquisitely tender to light touch (hyperal- at the site of the surgical incision. Given her ongoing gesic), while the inferior aspect of the closure was sub- marked clinical improvement and mild pain reported, acu- stantially less tender. There was no incisional drainage, puncture was not thought to be indicated by the clini- fluctuance, swelling, or bruising, and the area was not cian or patient. warm to the touch. That is, there was no clinical evi- The excisional biopsy accomplished complete re- dence of postoperative infection or hematoma at the sur- moval of a compound nevus and extended to the pan- gical site. The patient was afebrile. To help assess this niculus. The nevus showed focal areas of confluence and unusual postsurgical complication, the patient was evalu- mild cytologic atypia. The underlying dermis was oth- ated by one of us (T.D.R.) in the Department of Physical erwise unremarkable. Immunostaining for S-100 pro- Medicine and Rehabilitation at Mayo Clinic in Jackson- tein demonstrated the nevus cells but also was other- ville, Florida. wise unremarkable. No abnormality of nerves or other The patient was examined because of her complaints structures was noted. Congo red and sulfated alcian blue of increased pain at the site of the left thoracic excision stains for amyloid were negative. (REPRINTED) ARCH DERMATOL/ VOL 145 (NO. 1), JAN 2009 WWW.ARCHDERMATOL.COM 53 ©2009 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 COMMENT the procedure. The presence of this referred pain pat- tern in a soft-tissue structure overlying the latissimus dorsi muscle, rather than in the muscle itself, is not explained To our knowledge, this is the first reported case of a trig- by current theories of pathogenesis of myofascial trig- ger point located in the subcutaneous tissue overlying ger points.5,6 However, this presentation would be con- the latissimus dorsi muscle that produced a referred pain sistent with a neurophysiologic basis for myofascial pain pattern across the ipsilateral upper back and arm in a dis- syndrome,3 which suggests that trigger points are neu- tribution similar to that described for the latissimus dorsi rally mediated. The report by Shah et al7 provides fur- muscle.1,2 This trigger point was in a focal area superior to the surgical incision that was physically visible dur- ther evidence that trigger points are neurally mediated. 7 the authors found elevated biochemical ing dermatologic surgery, was unusually sensitive (hard In that study, mediators of pain and inflammation not only proximate to anesthetize), and produced marked local autonomic to