MYOFASCIAL PAIN SYNDROME(OMOHYOIDEUS-4 patients reports)

The JOURNAL OF CRANIOMANDIBULAR PRACTICE June '84-Aug. 'b4, Vol. 2, No. 3 The Omohyoideus Myofascial Pain Syndrome: Report of Four Patients Abstract Pain in the shoulder, neck, arm, and hand, and in the scapular, supraclavicular, mandibular, and temporal regions may be caused by the omohyoideus myofascial pain syndrome. This may be primary, caused by vomiting or by other intense use of the muscle, or it may be secondary, occurring as a result of rheumatoid myositis, ankylosing spondylitis, nonankylosing rheumatoid spondylitis, gouty myositis, or other disorders. The syndrome can be successfully treated by gently injecting the inferior belly of the omohyoideus muscle and the secondary trigger points with a combination of medications that will break the pain/spasm cycle. Michael R. Rask, M.D. Michael R. Rask, M.D. After receiving his M.D. degree from the University of Oregon Medical School in 1955, Dr. Rask completed his internship at Kings County Hospital in Brooklyn and later returned to Oregon for his orthopedic residency. He is currently in private practice in Las Vegas, Nevada, specializing in neurological orthopedic surgery. Dr. Rask belongs to a number of regional and national medical societies, including the American academy of neurological and Orthopaedic Surgeons, the American Federation for Medical Accreditation, and the Neurological and Orthopaedic Institute. Dr. Rask is chairman of the Board of Neurological and Orthopaedic Surgeons and editor-in-chief of The Journal of Neurological and Orthopaedic Surgery. He is also chairman of the Neurological Orthopaedic Institute. Dr. Rask has published nearly 200 articles in numerous major medical journals, and he has also presented a number of lectures and scientific exhibits at major scientific meetings. CASE REPORT The Omohyoideus Myofascial Pain Syndrome: Report of Four Patients By Michael R. Rask, M.D. Abundant material has been written about the thoracic inlet (or outlet) syndrome, the scalenus anticus muscle syndrome, the scalenus medius or posterior muscle syndromes, and cervical disk disease, but no attention has been paid to a painful and not infrequent muscle syndrome that has come to my notice over the years. The inferior belly of the omohyoideus muscle can cause a painful and disabling cervical-glenoappendicular disorder. This article will discuss four cases of this disorder, give some notes on the problem's etiology, and suggest a method for conservative treatment. Patient One This 54-year-old businessman had injured his lower back many years ago while lifting heavy objects. His L4-5 disk was damaged, and he had received no conservative therapy. After two unsuccessful lumbar laminectomies done by two different neurosurgrons, the patient developed severe and unrelenting cauda equina claudication (without intermittency). The patient responded well to the conservative therapeutic program I generally use for postoperative arachnoradiculitis.1 (This consists of intravenous Colchicine,* sodium salicylate, calcium gluconate, oral Colchicine and Anturane,* 2 and trigger point injections with Marcaine,* Sarapin,* and gamma globulin.3) After this conservative therapy, the patient returned home without much lower back or lower limb pain. However, he later became ill with influenza, and while he was vomiting, he has a sudden onset of severe pain in the neck and left shoulder. After several days of intense discomfort, the patient also began having severe, unrelenting left-sided temporo-parietal headache. The patient went to several practitioners in his hometown, who conducted numerous radiographic and electrical testings. These clinicians simply told him that it was related to his previous unsuccessful lower spine surgery. When I first examined the patient for this painful cervical condition in July, 1983, he was unable to extend or rotate his head and neck to the right without experiencing severe pain in the left supraclavicular area. This burning pain radiated into the left shoulder anteriorly and into the upper left brachium/elbow regions. There was also pain in the scapular insertion of the levator scapulae superioris muscle. Chest x-rays showed no evidence of a superior sulcus tumor, while a CT scan revealed some C5-6 disk "build-up" beneath the posterior longitudinal ligament without significant asymmetry. All other testing was negative, including laboratory procedures. (The patient did have mild adult-onset diabetes, but this was under good control with Diabinese.*) Examination of the patient's neck revealed extreme tenderness in the inferior belly of the omohyoideus muscle where it traversed the upper brachial plexus (Figure 1). No lymphadenopathy was present, nor was there marked tenderness in the brachial plexus itself. The subclavian artery pulsation could not be altered with the various arm abduction elevation and Valsalva procedures (negative Adson's and hyperabduction tests)4 that I attempted. The patient also had tenderness in the anterior bicipital groove of the left shoulder, in the scapular insertion of the levator scapulae superioris tendon, in the belly of the brachioradialis muscle, and in the midbelly of the temporalis muscle (just above the aygomatic arch). I found no sensory deficit (for light touch, temperature, or pinwheel pain) and no deep-tendon reflex deficit in the limbs. Nor was there muscle weakness anywhere in the upper left limb. Manipulating the inferior belly of the patient's left omohyoideus muscle re-created the severe neck, shoulder, and arm pain and headache. I carefully injected this muscle belly with Marcaine (bupicacaine hydrochloride 0.5%), gamma gloubulin, and Sarapin, using a 30 gauge ½ inch atraumatic, disposable needle. This completely relieved the patient's pain. On two subsequent occasions, I injected the secondary trigger points (in the bicipital groove and the scapular insertion of the levator scapulae superioris muscle), the muscle belly of the brachioradialis (at the left elbow), and the trigger point in the temporalis muscle in a similar manner. The patient was then able to return to his home with no pain and with no limitations to the movement in his shoulder and neck. His headache was also gone. Six months later I saw this patient again and found him to be totally asymptomatic. Patient Two This 49-year-old teacher developed food poisoning after eating some tainted fish. He became violently ill and was wretching and vomiting. Toward the end of the vomiting attack, he had a sudden burning pain in the right side of his neck and in his right shoulder blade, and aching in the right mandibular region. This pain persisted for three weeks. Buffered aspirin seemed to relieve the pain slightly. The patient found that turning his head to the left caused the pain in his neck and shoulder to become more intense. The pain also seemed worse in the morning. When I examined this patient three weeks after the onset of the syndrome, he had no sensory, motor, or deep-tendon reflex deficits. Radiographs of his neck showed no disk narrowing, and a chest x-ray showed no pathology there. The inferior belly of the patient's omohyoideus muscle was extremely tender to palpation, and the brachial plexus was slightly tender. There was also some tenderness at the cervical insertions of the lower three heads of the levator scapulae superioris muscle on the right side. The patient also had tenderness deep in the right levator scapulae superioris bursa on the inner upper aspect of the right scapula, and there was slight temporalis muscle tenderness above the aygomatic arch. Hyperextending the patient's head and turning it to the left (positive Spurling's test) aggravated his discomfort. (In Spurling's test for cervical radiculopathy, the pain and paresthesia can be reproduced by vertical compression of the head upon the neck. The neck may be extended, flexed, or bent laterally.4,8) I treated this patient by injecting the inferior belly of the right omohyoideus muscle with 2cc's of 0.5% Marcaine, ½ cc gamma globulin, and 1 cc Sarapin, taking great care not to anesthetize the right phrenic nerve (see Figure 2). This completely relieved the patient's discomfort. On the second visit, I injected the inferior belly of the omohyoideus muscle again, and I also injected the trigger points in the levator scapulae superioris muscle insertions and deep in the trapezius muscle (at the insertion of the omohyoideus muscle into the scapula). Three days later, the patient had no remaining symptoms. Patient Three After a severe rear-end collision in which her vehicle overturned, this 37-year-old secretary had developed Crohn's disease and nonankylosing rheumatoid spondylitis (NARS).5 (This had occurred 12 years before I saw her.) After seven years of chronic inflammatory disease in her neck, the patient began gradually to develop pain in the right supraclavicular area, the right shoulder, and the right upper brachium. She also experienced intense spasm of the levator scapulae superioris on the right side, and she had aching in her jaw, temporalis area headache, and burning in the inner upper aspect of the right scapula. She also had slight numbness in the tips of her fingers. Nonsteroidal anti-inflammatory medications afforded her only slight relief, and they often interfered with the Crohn's gastroenteritis. When I examined this patient, I found that she had the characteristic trigger point pain and tenderness in the inferior belly of the omohyoideus muscle. There was also tenderness of the brachial plexus. Radiographs of her neck revealed no disk narrowing, and there was no evidence of ankylosing spondylitis (the basis for the diagnosis of NARS).5 Spurling's test was positive for right shoulder and upper limb pain, but the patient's cervical movements were markedly limited, due to the inflammatory stiffness of her disease. I found no real sensory change or motor weakness and no deep tendon reflex abnormality in either upper limb. Maneuvers to identify thoracic inlet (or outlet) syndrome and scalenus anticus muscle syndrome were negative. I injected the inferior belly of the patient's right omohyoideus with 11/2 cc's of 0.5% Marcaine, 1 cc Sarapin, and ½ cc gamma globulin. This completely relieved the pain in her supraclavicular region and her right shoulder and mandibular areas for two to three months. The temporalis and levator scapulae superioris trigger points needed additional injections to give the patient greater pain relief. The usual ½ inch number 30 gauge disposable needle was used for all the injections. This helps to prevent the injection medication from escaping into the spinal nerve root dural sac and also eliminates the chance of injuring the cupola of the lung. Patient Four This patient is a 29-year-old concert pianist who had been in excellent health all of her life. Five months before she came to me, she was playing the piano fortissimo, when she suddenly felt an aching pain in the right cervical supraclavicular region, burning pain in the right shoulder, aching in the upper brachium, and pain in the upper inner shoulder blade. This pain waxed and waned for three months, occurring especially when she played the piano strenuously, and then it became constant. She also had some aching of her first digital web which had begun six weeks before she consulted me, and she had mandibular aching and intermittent headache. She had no numbness or tingling in her hand or upper limb. Left-sided neck movements increased her neck and arm discomfort. She had no history of neck injury. When I examined this patient in June, 1983, I found no sensory, motor, or deep-tendon reflex deficit in her right upper limb. There was extreme tenderness in the inferior belly of the omohyoideus muscle and some tenderness in the upper trunk of the brachial plexus (C5-6 roots). I found trigger points in the right bicipital groove, the brachioradialis muscle belly, the temporalis muscle belly (above the zygoma), the insertion of the levator scapulae superioris into the upper inner scapulae, and the first dorsal interosseous muscle. Moving her head to the left aggravated the patient's pain. Cervical and chest radiographs revealed no abnormalities, and CT scans of the C4-5, C5-6, and C6-7 disks showed no damage or tumor. HLA B-27 and antinuclear antibody titers were normal. I injected the inferior belly of the omohyoideus muscle carefully with the injection technique described above, and the patient's pain was completely relieved. I injected the other trigger points on two later occasions, and the patient returned to playing her piano fortissimo. Figure 1: Note how the inferior belly of the omohyoideus muscle traverses the upper portion of the brachial plexus. When this muscle goes into spasm primarily, as from intense vomiting, or secondarily, as a result of disk disease or other damage, the muscle belly become extremely painful. This will then cause a painful syndrome of neck, shoulder, and limb pain, temporalis muscle headache, and, in some patients, mandibular pain. The syndrome can disable the patient if it is not treated correctly. (Illustration from Atlas of Orthopadeic Exposures. Toufick Nicola, M.D. Baltimore: The Williams and Wilkins Company, 1966, pg. 62. Reprinted with the permission of the Williams and Wilkins Company.) Figure 2:The phrenic nerve is in close proximity of the inferior belly of the omohyoideus (retracted). Note also the proximity of the subclavian artery, subclavian vein the cupola of the lung, and the brachial plexus. These vital structures must not be disturbed in the injection procedure used in the treatment. It is thus essential to employ atraumatic injection techniques, using a 30 gauge 1/2 inch needle and injecting only small amounts of the medication mixture. Long acting bupivacaine (marcaine 0.5%) seems to be ideal for breaking the muscle pain/spasm cycle. (Illustration from Atlas of Orthopaedic Exposures. Toufick Nicola, M.D. Baltimore: The Wilkins Company, 1966, pg. 63. Reprinted with the permission of the Wilkins Company.) Figure 3: View of the anterior neck. The Omohyoideus muscle is attached by a central tendon to the clavicle and first rib. The infrahyoid belly of the muscle is flat and straplike, but the inferior belly is bulky and fleshy. Primary inflammation and spasm of the inferior belly can cause supra clavicular pain, burning in the shoulder and upper arm, elbow and lateral hand pain, sholder blade pain(rhumboid and levator scapulae superioris muscles), temporalis headache, and the mandibular aching. The may also become inflamed secondarily as a result of disk disease, ankylosing spondylitis, nonankylosing rheumatoid spodylitis, gouty myositis, rheumatoid myositis, and sprains or strains of the neck and sholder girdle.(Illustration fromSobotta: Atlas of Human Anatomy. Helmut Ferner and Jochen Straubsand, eds. 10th English Ed. Baltimore: Urban and Schwarzenberg, 1983. Reprinted with the permission of Urban and Schwarzenberg.) Figure 4: Simplified drawing showing the attachments of the omohyoideus muscle. Notice the central tendon and the scapular attachment of this multi-functioning muscle. (Illustration of from Anson's Atlas of Human Anatomy. Barry J. Anson, ed. Philadelphia: The W.B. Sanuders Company, 1950. Reprinted with the permission of the W.B. Sanuders Company.) Anatomy of the Omohyoideus Muscle The omohyoideus muscle arises from the upper margin of the scalpula, near (and sometimes from) the suprascalpular ligament (see Figure 4). It attaches to the hyoid bone. The superior belly of the omohyoideus is like an infrahyoid “strap” muscle, while the inferior belly of the muscle is thick and fleshy. This inferior portion of muscle crosses over the upper trunk of the brachial plexus (C-5 and C-6) (se Figure 3). The central tendon of the omohyoideus muscle is beneath the sternocleidomastoid muscle and separates the two bellies (Figure 3). This central tendon is held in place by the strong process of the middle layer of cervical fascia. The fascial process helps attach the omohyoideus mid-muscular tendon to the posterior surfaces of the clavicle and first rib. The nerve supply for both the bellies of the omohyoideus muscle is derived from ansa cervicalis (C1-2-3, and sometimes C-4). (In older anatomy books, ansa cervicalis is called ansa hypoglossi). In the fetus, the omohyoideus muscle is longitudinal and starp-like (as is the rest of the infrahyoid musculature), but it moves with clavicle and scapula as they grow, taking on its unusual character. Its function is to assist in swallowing, vomiting, and respiration, and it also has some scapulo-clavicular actions. Etiology of the Omohyoideus Muscle Pain Syndrome This omohyoideus muscle pain disorder may be either primary or secondary. Any muscle can be the primary site for a painful contraction syndrome, 6 and if the muscle is located in a strategic place, then the muscle pain/spasm cycle that occurs will have even more wide spread results. The omohyoideus is of course such a case, since the brachial plexus is located beneath it. Because there is a great cross-over of the nerve supply for the muscle (the ansa cervicalis), there can also be referred pain in similarly innervated structures. This can create seemingly unrelated symptoms such as temporalis headache, sympathetic pain in the levator scapulae superioris muscle, the inframandibular pain on the affected side. (These structures share segmental innervation of the omohyoideus.) In addition, since the upper trunk of the brachial plexus (C5 and C6 spinal nerve roots) is so near, contiguous inflammation from the muscle may cause the patient’s neck and supraclavicular pain in progress into his or her entire upper limb. However, the trouble arises primarily from two-bellied omohyoideus muscle. Primarily isolated muscular disease may occur in the omohyoideus muscle as a result of the violent, intense vomiting (as in patients 1 and 2) or violent shoulder and neck movement (as in patient 4). However, the syndrome can also occur secondarily, as a result of rheumatoid myositis, ankylosing spondylitis, nonankylosing rheumatoid spondylitis (as in patient 3), gouty myositis, cervical spine injuries, or disk damage in the region. In addition to isolated viral inflammation of muscle or nerves, muscular inflammation may also occur as a result of joint diseases, trauma, spinal cord lesions brachial plexus neuropathy (Parsonnage-Turner syndrome), poliomyelitis, Guillain-Barré syndrome, polyneuropathies (alcoholism, porphyria, arsenic intoxication), polyneuritis nodosa, lupus, rheumatoid arthritis, diabetes, beriberi, B12 deficiency, or other problems. 6 For older patients, the cliician must also consider the possibility of polymyalgic rheumatica. (Temporary arteritis is a peculiar component of that disorder.) Diagnosis A diagnosis of primary omohyoideus myofascial pain syndrome should be made only after careful tactile examination of the patient’s supraclavicular fossa, and after other causes for the cervical, supraclavicular, scapular, temporomandibular, and limb pain have been excluded. One example of another cause can be seen in the patient who has Horner’s syndrome (meiotic pupil, ptosis of the eyelid, narrowing of the palpebral fissure, and anhidrosis and flushing of the affected side of the face) with a cloudy radiologic lesion in the cupola of the lung. These symptoms would indicate that the patient has a sulcus neoplasm, and we must assume this to be the case until proven otherwise. The clinician must search for all such possible cervical disease, brachial plexus problems, and cervical spinal nerve root abnormalities and exclude them in order to arrive at diagnosis of primary omohyoideus myofascial pain syndrome. However, whether omohyoideus muscular inflammation or spasm is diagnised as a primary or secondary, the conservative therapy used is the same. Contradictions for this treatment would include malignant infiltration of the brachial plexus (and omohyoideus muscle), carries sicca, or any other treatable inflammatory condition. If any of these conditions are present, the clinician must not inject this area of the body to relieve the pain. Although omohyoideus muscle in the supraclavicular fossa will be extremely teder, there should be little, if any, sensory abnormality in the upper limb, and there should be no deep tendon reflex changes. In addition, the brachial plexus should not be more tender than the omohyoideus muscle. There may also be trigger points found in the bicipital groove of the shoulder, the insertion of the deltoid into the humerus, the brachioradialis muscle belly at the elbow, the first dorsal interosseous muscle, the levator scalpulae superioris muscle (both proximal and distal attachments), the rhumboid muscles, deep in the supraspinatus muscle where omohyoid attaches to the transverse scapular ligament, the mid-cervical apophyseal joints, the temporalis muscle, or even temporomandibular joint itself. Treatment The injection treatment must be performed gently with a technique as atraumatic as possible. I use a number 30 gauge ½ inch needle to deliver a small amount of the following mixture: 1 ½ cc’s of bupivocaine (Marcaine 0.5%), 1 cc Sarapin, and ½ cc globulin. This anesthetizes the fleshy inferior belly of omohyoideus muscle, which breaks the spasm /inflammatory cycle that has caused the trouble. The simpler and gentler the technique used, the better and more effective it is for the patient Although it is not necessary to infiltrate the brachial plexus in primary omohyoideus muscle pain syndrome, spinal nerve root blocks are quite effective in muscle spasm, that is secondary to cervical disk disease. The clinician must also inject the secondary trigger point areas described above with the same mixture of medications and same gentle technique. It is acceptable to use small amount of triamcinolone acetonide with medication mixture, but I have found that dexamethasone and other long-acting, slow-dissolving synthetic gluconeocorticoids are irritating and not too effective in the lon run. In addition to this injection, it often helps to give the patient prostaglandin inhibitors. I use a mixture of intravenous Colchcine, sodium salicylate, and calcium gluconate for this. Non steroidal oral anti-inflammatory medications such as Naprosyn* (naproxen), Clinoril,* and Tolectin* also seem to help. Narcotics, Muscle relaxants, and tranquilizers such as Valium* (diazepam), should not be used in treating this painful syndrome. These drugs are habit-forming, and they do nothing to relieve the disorder. Once the spastic muscle has been treated by injection, it is no longer for the patient to rest the neck and limb. Although I have not found surgical therapy to be necessary in treating the omohyoideus myofiscial pain syndrome, it is possible that a resistant and recurrent spastic muscle condition would make it necessary to divide the omohyoideus muscle. If this has to be dome, the muscle should be excised from the central tendon past the point where it crosses the patient's brachial plexus. At the same time, muscle and lymph nodes may be taken for biopsy. Summary The omohyoideus myofascial pain syndrome described here can cause severe pain in the neck, shoulder, arm, elbow, and hand, and in the scapular, supraclavicular, mandibular, and temporal regions. The syndrome is due to spastic inflammation of the fleshy inferior belly of the omohyoidues muscle. Once it has been determined that other more serious problems have not been the cuase of the spasm and pain, the condition can be treated easily with a gentle, atraumatic injection technique. Reprint requests to: Dr. Michael R. Rask Sahara Raincho Medical Center 2320 Rancho Dr., Suite 108 Las Vegas, Nevada 89102-4592 References 1. Rask, M.R. Postoperative arachnoradiculitis: report of 24 patients and the conservative treatment therefore. J Neurol Orthop Surg 1980: 1: 157-166. 2. Rask, M.R. The occurrence of acute gout in a patient with a healing fractured metatarsal. J Neurol Orthop Surg 1983: 4(3): 263-267. 3. Rask, M.R. On the use of gamma globulin for local triggerpoint, intra-anticular and spinal nerve root injections. J Neurol Orthop Surg 1983: 4(1): 92. 4. Rask, M.R. Signs of our neurological-orthopaedic times. J Neurol Orthop Surg 1980: 1: 251-255. 5. Rask, M.R. Non-ankylosing rheumatoid splondylitis (NARS): report of 11 patients. Orthop Rev 1982: 9: 21-33. 6. Nakano, K.K. Neurology of Musculoskeletal and Rheumatic Disorders. Boston: Houghton-Mifflin Professional Publishers. 1979, pp.11-12 7. Rask, M.R. Ipsilateral hip, knee and shin pain in a rheumatoid with an artificial hip. J Neurol Orthop Surg 1983: 4: 129-142. 8. Nakano, K.K. Entrapment neuropathies. In textbook. Kelley. Ed. Philadelphia: W.B. Saunders Company. 1982. 9. Travell, J.G., and Simons, D.G. Myofascial Pain and Dysfunction: The Trigger Point Manual. Baltimore: The Williams and Wilkins Company. 1983. pp. 354-355. *Colchicine-Eli Lilly and Company, Indianapolis, Indiana. *Anturane-GEIGY Pharmaceuticals, Ardsley, New York. *Marcaine-Winthrop Laboratories, New York, New York. *Sarapin-High Chemical Co., Division of Day Frick, Inc., Philadelphia, Pennsylvania *Diabinese-Pfizer Laboratories Division, Pfizer Inc., New York, New York. *Naprosyn-Syntex Laboratories, Inc., Palo Alto, California. *Clinoril-Merck Sharp & Dohme, West Point, Pennsylvania. *Tolectin-McNeil Pharmaceutical, Spring House, Pennsylvania. *Valium-Roche Laboratories, Division of Hoffman-LaRoche, Inc., Nutley, New Jersy. Home