Ultrasound Guidance for Botulinum Neurotoxin Chemodenervation Procedures

Trans-axillary sonography in the ABER (ABduction and External Rotation) position: a window to the subscapularis, teres major and latissimus dorsi

Shoulder ultrasound is a key tool used by musculoskeletal practitioners to diagnose and treat a variety of upper girdle diseases. While magnetic resonance imaging is the cornerstone of shoulder imaging, sonography is readily available, practical and superior in its ability for dynamic assessment of musculoskeletal pathologies. The subscapularis, teres major and latissimus dorsi muscles are commonly involved in a myriad of pathology including myofascial pain and spasticity. There is scarce literature on the assessment of these muscles for diagnostic and therapeutic purposes. Conventional approaches to shoulder ultrasound have not included a dedicated assessment of the subscapularis muscle due to its inherent anatomical location deep to the scapular blade which blocks sound wave penetration. We describe an approach to visualizing the subscapularis muscle as a short addition to the established shoulder sonography format, which also permits assessment of both the latissimus dorsi and teres major muscles, which are important muscles for shoulder spasticity. The patient is imaged in a semi-recumbent position with the arms elevated above and behind the head in the ABduction and External Rotation (ABER) position. The relative ease of positioning and sonographic access to the musculature coupled with the potential for assessment and intervention makes this approach extremely desirable to the musculoskeletal practitioner looking to diagnose or treat muscle belly pathologies of the subscapularis, teres major or latissimus dorsi.

Enhancing Botulinum Toxin Injection Precision: The Efficacy of a Single Cadaveric Ultrasound Training Intervention for Improved Anatomical Localization

Ultrasound guidance can enhance existing landmark-based injection methods, even through a brief and single exposure during a cadaveric training course. A total of twelve participants were enrolled in this training program, comprising nine physical medicine and rehabilitation specialists, one pediatrician, and two physician assistants. For each participant, one upper-limb muscle and one lower-limb muscle were randomly chosen from the preselected muscle group. Subsequently, participants were tasked with injecting both of their chosen cadaveric muscles with 1 mL of acrylic paint using a manual needle palpation technique, relying solely on their knowledge of anatomic landmarks. Participants then underwent a personalized, one-to-one ultrasound teaching session, lasting approximately five minutes, conducted by two highly experienced instructors. Following this instructive phase, participants were tasked with a second round of injections, targeting the same two muscles in the lower and upper limbs. However, this time, the injections were performed using anatomical landmarks and ultrasound guidance. To facilitate differentiation from the initial injections, a distinct color of acrylic paint was employed. When employing the anatomical landmark-based approach, the overall success rate for injections was 67%, with 16 out of 24 targeted muscles accurately injected. With the incorporation of ultrasound guidance, the success rate was 92%, precisely targeting 22 out of the 24 muscles under examination. There was an improvement in injection accuracy achievable through the integration of ultrasound guidance, even with minimal training exposure. Our single cadaveric ultra-sound training program contributes valuable insights to the utilization of ultrasound for anatomy training to help optimize the targeting of BoNT-A.

Assessing muscle architecture with ultrasound: implications for spasticity

Botulinum Neurotoxin Type A (BoNT-A) injections using Ultrasound (US) guidance have led to research evaluating changes in muscle architecture. Controversy remains as to what constitutes increased Echo-Intensity (EI) in spastic muscles and whether this may affect outcomes. We aim to provide a narrative review of US muscle architecture changes following Central Nervous System (CNS) lesions and explore their relationship to spasticity. Medline, CINAHL, and Embase databases were searched with keywords: ultrasonography, hypertonia, spasticity, fibrosis, and Heckmatt. Three physicians reviewed the results of the search to select relevant papers. Reviews identified in the search were used as a resource to identify additional studies. A total of 68 papers were included. Four themes were identified, including histopathological changes in spastic muscle, effects of BoNT-A on the muscle structure, available US modalities to assess the muscle, and utility of US assessment in clinical spasticity. Histopathological studies revealed atrophic and fibro-fatty changes after CNS lesions. Several papers described BoNT-A injections contributing to those modifications. These changes translated to increased EI. The exact significance of increased muscle EI remains unclear. The Modified Heckmatt Scale (MHS) is a validated tool for grading muscle EI in spasticity. The use of the US may be an important tool to assess muscle architecture changes in spasticity and improve spasticity management. Treatment algorithms may be developed based on the degree of EI. Further research is needed to determine the incidence and impact of these EI changes in spastic muscles.

The effectiveness of ultrasound-guided injection of BTX-A in the management of sialorrhea in neurogenic dysphagia patients

Objective

To evaluate the effectiveness of ultrasound-guided injection of botulinum toxin type A (BTX-A) in treating sialorrhea.

Methods

We recruited 32 sialorrhea subjects and they received an ultrasound-guided injection of BTX-A. The extent of salivation was evaluated according to the Visual Analog Scale (VAS), Drooling Severity and Frequency Scale (DSFS), and Saliva Flow Rate (SFR). Laryngeal secretions were evaluated based on Fiberoptic Endoscopic Evaluation of Swallowing (FEES) rated according to the Murray Secretion Scale (MSS). We assessed the extent of salivation and laryngeal secretions before injection and at 1, 2, and 4 weeks after injection.

Results

The scores for the VAS, DSFS-S, DSFS-F, and DSFS-T decreased significantly at 1, 2, and 4 weeks after injection compared with before injection (p < .05). Based on VAS, the efficacy was substantially higher at 2 and 4 weeks after injection than at 1 week after injection (p < .05). According to DSFS-S and DSFS-T, the efficacy was significantly higher at 4 weeks than at 1 week after injection (p < .05). The SFR and MSS scores at 1 and 2 weeks after injection were superior to those before injection (p < .05). Meanwhile, the SFR score 2 weeks after injection was superior to that 1 week after injection (p < .05).

Conclusion

The ultrasound-guided injection of BTX-A can effectively reduce saliva secretion in patients with neurogenic dysphagia. Furthermore, it has the advantages of early onset time and lasting curative effects, which indicates that clinical promotion and application of this technique are justified.

Level of Evidence

Level 3.

Longitudinal Assessment of Botulinum Toxin Treatment for Lateral Trunk Flexion and Pisa Syndrome in Parkinson's Disease: Real-life, Long-Term Study

Lateral trunk flexion (LTF) and its severe form, called Pisa syndrome (PS), are highly invalidating axial postural abnormalities associated with Parkinson's disease (PD). Management strategies for LTF lack strong scientific evidence. We present a real-life, longitudinal study evaluating long-term efficacy of botulinum toxin (BoNT) injections in axial muscles to reduce LTF and PS in PD. A total of 13 PD patients with LTF > 5° received ultrasound- and electromyography-guided BoNT injections every 4 months. Seven untreated matched PD patients with LTF served as controls and their changes in posture after 18 months were compared with those of seven patients continuing BoNT over 12 months. 53.8% of patients continued the BoNT injections for at least 12 months. Various individual LTF responses were observed. Overall, BoNT-treated patients obtained a not statistically significant improvement of LTF of 17 ± 41% (p = 0.237). In comparison, the seven untreated PD patients suffered a deterioration in LTF over 12 months by 36 ± 45% (p = 0.116), showing a significantly different trajectory of posture change (p = 0.026). In conclusion, repeated BoNT injections in axial muscles showed varying effects in managing PD-associated LTF, suggesting that: (a) a relevant number of patients with LTF can benefit from BoNT; (b) long-term treatment could prevent LTF worsening; (c) an instrumented, personalized approach is important; and (d) there is a need for prospective, long-term studies.

In-Plane Ultrasound-Guided Botulinum Toxin Injection to Lumbrical and Interosseus Upper Limb Muscles: Technical Report

This technical report presents an innovative approach utilizing in-plane ultrasound-guided injections to precisely target the lumbrical and interosseous muscles within the upper limb. The report also elucidates the rationale and advantages of incorporating ultrasound guidance in the administration of Botulinum toxin (BTX) injections, encompassing the real-time visualization of needle trajectory and accurate localization of the target muscle groups while delving into the pertinent anatomical details of these muscles and their significance in diverse neuromuscular conditions. The step-by-step procedure for conducting in-plane ultrasound-guided BTX injections to the lumbrical and interosseous muscles is delineated, emphasizing critical technical considerations and potential pitfalls to be vigilant of during the procedure. Furthermore, the article addresses the significance of selecting appropriate BTX dosages and injection sites based on individual patient presentations and clinical indications. Overall, the in-plane ultrasound-guided BTX injection technique presents a promising approach for providing precise and targeted treatment to the lumbrical and interosseous muscles in the upper limb. It offers clinicians an alternative to injections performed without guidance or out-of-plane ultrasound-guided injections, potentially decreasing the likelihood of complications and enhancing treatment outcomes for patients with a range of neuromuscular conditions. However, further research and comparative studies are necessary to establish the long-term efficacy and safety of this technique, thus confirming its role in clinical practice.

Recommendations for Ultrasound Guidance for Diagnostic Nerve Blocks for Spasticity. What Are the Benefits?

The diagnostic nerve block (DNB) for spasticity is the percutaneous application of an anesthetic to an individual peripheral nerve trunk (mixed motor sensory nerve), nerve branch to a muscle or an intramuscular branch. The DNB causes a temporary paralysis to assess the contribution of muscle(s) on the spastic pattern and may unmask a fully or partially increased joint range of motion. The anesthetic literature supports the use of ultrasound (US) guidance to improve nerve blocks for sensory targets. This communication summarizes the potential advantages that support the use of US to improve DNB technique. Nerves are much smaller than muscle targets and have various known innervation patterns. US allows for rapid localization of the target before injection, particularly in complex anatomy patterns. The nerve trunks are typically found adjacent to or encapsulating blood vessels, which can be quickly identified with or without color Doppler, allowing the clinician to scan from the vessels to the target and avoid intravascular injection. Lower stimulation levels can be used as the targeted muscle(s) can be seen stimulating rather than only on the surface. A shorter needle insertion time and lower stimulation levels should cause less discomfort to the patient. Smaller volumes of anesthetic may be used as the fluid is seen reaching its target and cessation of stimulation is observed. Further study is needed to identify evidence supporting US utilization with electrical stimulation in DNBs for spasticity management, as US use during nerve blocks for perineurial anesthesia has demonstrated improved patient safety and procedural efficiency.

Postoperative ecchymoma of eyelid after botulinum toxin injection for hemifacial spasm: a case report

Hemifacial spasm (HFS) is a rare movement disorder characterized by involuntary muscle contractions on one side of the face. Compared to the high therapeutic effect, adverse effects of botulinum toxin treatment for HFS occurred rarely. However, managing HFS patients who are also taking antithrombotic drugs poses a challenge. Here, we present a case of postoperative ecchymoma of the eyelid following a botulinum toxin injection in a patient receiving daily vinpocetine and aspirin antiplatelet therapy. This case highlights the importance of considering the potential risks and formulating a treatment plan that maximizes benefit while minimizing complications in HFS patients undergoing botulinum toxin injections and taking antithrombotic medications. To the best of our knowledge, this is the first reported case of postoperative ecchymoma of the eyelid following a botulinum toxin injection. Further research and additional case reports are needed to better understand the management strategies for this patient population.

A Bayesian Network Meta-Analysis and Systematic Review of Guidance Techniques in Botulinum Toxin Injections and Their Hierarchy in the Treatment of Limb Spasticity

Accurate targeting of overactive muscles is fundamental for successful botulinum neurotoxin (BoNT) injections in the treatment of spasticity. The necessity of instrumented guidance and the superiority of one or more guidance techniques are ambiguous. Here, we sought to investigate if guided BoNT injections lead to a better clinical outcome in adults with limb spasticity compared to non-guided injections. We also aimed to elucidate the hierarchy of common guidance techniques including electromyography, electrostimulation, manual needle placement and ultrasound. To this end, we conducted a Bayesian network meta-analysis and systematic review with 245 patients using the MetaInsight software, R and the Cochrane Review Manager. Our study provided, for the first time, quantitative evidence supporting the superiority of guided BoNT injections over the non-guided ones. The hierarchy comprised ultrasound on the first level, electrostimulation on the second, electromyography on the third and manual needle placement on the last level. The difference between ultrasound and electrostimulation was minor and, thus, appropriate contextualization is essential for decision making. Taken together, guided BoNT injections based on ultrasound and electrostimulation performed by experienced practitioners lead to a better clinical outcome within the first month post-injection in adults with limb spasticity. In the present study, ultrasound performed slightly better, but large-scale trials should shed more light on which modality is superior.

A practical guide to botulinum neurotoxin treatment of shoulder spasticity 2: Injection techniques, outcome measurement scales, and case studies

Introduction

Botulinum neurotoxin type A (BoNT-A) is a first-line treatment option for post-stroke spasticity, reducing pain and involuntary movements and helping to restore function. BoNT-A is frequently injected into the arm, the wrist, the hand, and/or the finger muscles but less often into the shoulder muscles, despite clinical trials demonstrating improvements in pain and function after shoulder BoNT-A injection.

Methods

In part 2 of this two-part practical guide, we present an experts' consensus on the choice of outcome measurement scales and goal-setting recommendations for BoNT-A in the treatment of shoulder spasticity to increase awareness of shoulder muscle injection with BoNT-A, alongside the more commonly injected upper limb muscles. Expert consensus was obtained from five European experts with a cumulative experience of more than 100 years of BoNT-A use in post-stroke spasticity. Case studies are included as examples of approaches taken in the treatment of shoulder spasticity.

Results

Although the velocity-dependent increase in muscle tone is often a focus of patient assessment, it is only one component of spasticity and should be assessed as part of a wider range of measurements. For outcome measurement following BoNT-A injection in shoulder muscles, shoulder-specific scales are recommended. Other scales to be considered include Pain Numerical Rating and/or global functioning, as well as the quality of life and global perception of benefit scores.Goal setting is an essential part of the multidisciplinary management process for spasticity; goals should be patient-centric, realistic, and achievable; functional-focused goal statements and a mixture of short- (3-6 month) and long-term (9-18 month) goals are recommended. These can be grouped into symptomatic, passive function, active function, involuntary movement, and global mobility.Clinical evaluation tools, goal setting, and outcome expectations for the multipattern treatment of shoulder spasticity with BoNT-A should be defined by the whole multidisciplinary team, ensuring patient and caregiver involvement.

Discussion

These recommendations will be of benefit to clinicians who may not be experienced in evaluating and treating spastic shoulders.

Post Hoc Subgroup Analysis of the BCause Study Assessing the Effect of AbobotulinumtoxinA on Post-Stroke Shoulder Pain in Adults

Botulinum toxin type A is approved for the focal treatment of spasticity; however, the effectiveness of abobotulinumtoxinA (aboBoNT-A) in patients with shoulder pain who have set reduced pain as a treatment goal is understudied. In addition, some patients encounter delays in accessing treatment programs; therefore, the suitability of aboBoNT-A for pain reduction in this population requires investigation. These factors were assessed in aboBoNT-A-naive Brazilian patients in a post hoc analysis of data from BCause, an observational, multicenter, prospective study (NCT02390206). Patients (N = 49, n = 25 female; mean (standard deviation) age of 60.3 (9.1) years; median (range) time since onset of spasticity of 16.1 (0-193) months) received aboBoNT-A injections to shoulder muscles in one or two treatment cycles (n = 47). Using goal attainment scaling (GAS), most patients achieved their goal of shoulder pain reduction after one treatment cycle (72.1%; 95% confidence interval: 57.2-83.4%). Improvements in GAS T-score from baseline, clinically meaningful reductions in pain score at movement, and clinically meaningful increases in passive shoulder abduction angle further improved with repeated treatment more than 4 months later, despite treatment starting at a median of 16.1 months after the onset of spasticity. These findings support the further investigation of aboBoNT-A injections in chronic post-stroke shoulder pain.

Incobotulinum toxin A with a one-year long-lasting effect for trapezius contouring and superior efficacy for the treatment of trapezius myalgia

Context:

Based on various Botulinum toxin A products, reports of the lower efficacy of Incobotulinum toxin A compared with Onabotulinum toxin A for muscle contouring were observed. In addition, complications of trapezius myalgia and shoulder contouring treatment from malpractice have been reported.

Aims:

The study aimed at comparing the efficacy between Incobotulinum toxin A and Onabotulinum toxin A; research was conducted on a safe treatment technique for trapezius hypertrophy and trapezius myalgia.

Materials and Methods:

A split-shoulder, double-blind, randomized controlled trial was performed. Twenty volunteers with trapezius hypertrophy and trapezius myalgia were randomly injected with 30 units of Incobotulinum toxin A and Onabotulinum toxin A in each trapezius muscle guided by ultrasound.

Results:

The trapezius thickness among those receiving treatment with Onabotulinum toxin A and Incobotulinum toxin A on day 60 was 7.35 ± 1.11 and 7.33 ± 1.21 mm, respectively, which did not portray a significant difference (P = 0.991). Compared with the muscle size from day 60 to one year, the size of the trapezius muscle that had been treated by Onabotulinum toxin type A regained a significantly larger size compared with that treated by Incobotulinum toxin A (P = 0.027). On comparing the size of the trapezius muscle treated by Incobotulinum toxin A between one year and day 0, it was observed that the trapezius thickness at one year had significantly decreased (P < 0.001). On comparing the pain score from day 60 to day 0, it was observed that the pain scores of trapezius myalgia treated by Onabotulinum toxin A and Incobotulinum toxin A significantly differed (P = 0.003).

Conclusions:

Incobotulinum toxin A had the same efficacy but a longer lasting effect for the trapezius size contouring and a higher efficacy for trapezius myalgia treatment compared with Onabotulinum toxin A.

Ultrasonographic Evaluation of Three Approaches for Botulinum Toxin Injection into Tibialis Posterior Muscle in Chronic Stroke Patients with Equinovarus Foot: An Observational Study

Spastic equinovarus (SEV) foot deformity is commonly observed in patients with post-stroke spasticity. Tibialis posterior (TP) is a common target for botulinum toxin type-A (BoNT-A) injection, as a first-line treatment in non-fixed SEV deformity. For this deep muscle, ultrasonographic guidance is crucial to achieving maximum accuracy for the BoNT-A injection. In current clinical practice, there are three approaches to target the TP: an anterior, a posteromedial, and a posterior. To date, previous studies have failed to identify the best approach for needle insertion into TP. To explore the ultrasonographic characteristics of these approaches, we investigated affected and unaffected legs of 25 stroke patients with SEV treated with BoNT-A. We evaluated the qualitative (echo intensity) and quantitative (muscle depth, muscle thickness, overlying muscle, subcutaneous tissue, cross-sectional area) ultrasound characteristics of the three approaches for TP injection. In our sample, we observed significant differences among almost all the parameters of the three approaches, except for the safety window. Moreover, our analysis showed significant differences in cross-sectional area between treated and untreated. Advantages and disadvantages of each approach were investigated. Our findings can thus provide a suitable reference for clinical settings, especially for novice operators.

AbobotulinumtoxinA provides flexibility for the treatment of cervical dystonia with 500 U/1 mL and 500 U/2 mL dilutions

INTRODUCTION

Cervical dystonia (CD) is a neurologic movement disorder with potentially disabling effects and significant impact on quality of life of those affected. AbobotulinumtoxinA (aboBoNT-A) was initially approved for a dilution of 500 U/1 mL and subsequently for a dilution of 500 U/2 mL, providing flexibility for clinicians to treat CD. Here, we explore the safety and efficacy of the 500 U/2 mL dilution versus 500 U/1 mL dilution of aboBoNT-A in a retrospective analysis based on published clinical trial data.

METHODS

The safety and efficacy of aboBoNT-A in patients with CD was evaluated in three multicenter, double-blind, randomized, placebo-controlled trials and open-label extensions. Trials 1 (NCT00257660) and 2 (NCT00288509) evaluated the 500 U/1 mL dilution in 80 and 116 patients, respectively; Trial 3 (NCT01753310) evaluated the 500 U/2 mL dilution in 125 patients.

RESULTS

Comparison of the adjusted mean difference in TWSTRS total scores at Week 4 from baseline for aboBoNT-A in Trial 1 (-6.0; 95% CI, -10.8, -1.3), Trial 2 (-8.8; 95% CI, -12.9, -4.7), and Trial 3 (-8.7; 95% CI, -13.2, -4.2) showed similar, significant improvements. Dysphagia and muscle weakness patterns were comparable across the three trials, indicating that an increased dilution of aboBoNT-A does not result in an increased risk of diffusion-related adverse events.

CONCLUSION

The results of these trials show that aboBoNT-A is similarly efficacious using either dilution, with similar safety and tolerability across trials. Having the 500 U/1 mL and 500 U/2 mL dilution volumes available provides further flexibility in administration, benefiting patient care.

A consensus statement on the use of botulinum toxin in pediatric patients

Botulinum toxin has been used in medicine for the past 30 years. However, there continues to be controversy about the appropriate uses and dosing, especially in the pediatric population. A panel of nine pediatric physiatrists from different regions and previous training programs in the United States were nominated based on institutional reputation and botulinum toxin (BoNT) experience. Based on a review of the current literature, the goal was to provide the rationale for recommendations on the administration of BoNT in the pediatric population. The goal was not only to review safety, dosing, and injection techniques but also to develop a consensus on the appropriate uses in the pediatric population. In addition to upper and lower limb spasticity, the consensus also provides recommendations for congenital muscular torticollis, cervical dystonia, sialorrhea, and brachial plexus palsies.

Impact of Predefined Angles and a Revised APPLES Mnemonic on Accuracy and Performance Time for Simulated Ultrasound-Guided Injections

OBJECTIVES

Our objective was to determine whether predefined angles would improve performance time and accuracy of ultrasound-guided procedures by novice operators and whether a revised APPLES (approach, position, perpendicular, lift, entry, sweep) mnemonic was a helpful guide for performing the procedure.

METHODS

Participants attempted to hit targets in-plane and out-of-plane at different depths with a needle under ultrasound guidance with and without predefined angles. Participants were then asked if they thought that the mnemonic would be helpful when learning both methods for ultrasound-guided procedures.

RESULTS

There were 120 participants all of whom had performed fewer than six ultrasound guided procedures. Accuracy increased in all groups when angles were provided; however, only the 3-cm in-plane approach achieved statistical significance. Performance time also achieved statistical significance in two of the four groups. Ninety-five percent of participants thought that the revised APPLES mnemonic would be helpful for learning and performing ultrasound-guided procedures in the future.

CONCLUSIONS

Predefined angles seem to positively impact procedure time and accuracy for some target depths, and the APPLES mnemonic could be a helpful mental checklist for many novice operators. These may be useful tools to facilitate safe and efficient ultrasound-guided procedures in the clinical space.

Ergonomic Recommendations in Ultrasound-Guided Botulinum Neurotoxin Chemodenervation for Spasticity: An International Expert Group Opinion

Ultrasound (US)-guided botulinum neurotoxin (BoNT) injections are becoming a mainstay in the treatment of muscle spasticity in upper motor neuron syndromes. As a result, there has been a commensurate increase in US-guided BoNT injection for spasticity training courses. However, many of these courses do not emphasize the importance of ergonomics. This paper aims to highlight the importance of ultrasound ergonomics and presents ergonomic recommendations to optimize US-guided BoNT injection techniques in spasticity management. Expert consensus opinion of 11 physicians (4 different continents; representing 8 countries, with an average of 12.6 years of practice using US guidance for BoNT chemodenervation (range 3 to 22 years)). A search using PubMed, College of Physicians and Surgeons of British Columbia database, EMbase was conducted and found no publications relating the importance of ergonomics in US-guided chemodenervation. Therefore, recommendations and consensus discussions were generated from the distribution of a 20-question survey to a panel of 11 ultrasound experts. All 11 surveyed physicians considered ergonomics to be important in reducing physician injury. There was complete agreement that physician positioning was important; 91% agreement that patient positioning was important; and 82% that ultrasound machine positioning was important. Factors that did not reach our 80% threshold for consensus were further discussed. Four categories were identified as being important when implementing ultrasound ergonomics for BoNT chemodenervation for spasticity; workstation, physician, patient and visual ergonomics. Optimizing ergonomics is paramount when performing US-guided BoNT chemodenervation for spasticity management. This includes proper preparation of the workspace and allowing for sufficient pre-injection time to optimally position both the patient and the physician. Lack of awareness of ergonomics for US-guided BoNT chemodenervation for spasticity may lead to suboptimal patient outcomes, increase work-related injuries, and patient discomfort. We propose key elements for optimal positioning of physicians and patients, as well as the optimal setup of the workspace and provide clinical pearls in visual identification of spastic muscles for chemodenervation.

Ultrasound Imaging of Injections in Masseter Muscle without Contrast Agent Using Strain Elastography and a Novel B-Mode Spatiotemporal Filter

Botulinum toxin type A (BTX-A) injections in masseter muscle can alleviate muscle tightness and aching pain caused by idiopathic masticatory myalgia, a subform of the myofascial pain syndrome. Yet the injection procedure (number, amount) is currently empirical. In this ex vivo study, we determined the feasibility of using contrast-free ultrasound imaging to visualize the short-term injectate propagation. Ultrasound annotations of BTX-A injectate spread in N = 12 porcine masseter muscles were compared with the histopathology of the excised masseter. BTX-A presence was automatically detected in the ultrasound cine by: compensating tissue motion and deformation during injection with a novel spatiotemporal filtering (SF) algorithm, and by imaging tissue swelling strains with strain elastography (SE). BTX-A injectate introduced 6.5% (standard deviation = 5.0%) echogenicity contrast and 13.9% (standard deviation = 3.7%) tissue swelling strain. Muscle fasciae were a border for BTX-A distribution. The SF algorithm achieved significantly higher noise rejection (contrast-to-noise ratio = 4.63) than SE (2.56, p = 0.01), and state-of-the-art 2-D digital image correlation (1.81, p < 0.001) and direct image subtraction (1.29, p < 0.001) methods. Histopathology agreed well with ultrasound (Dice coefficient = 0.48), with deviations mainly explained by the three-dimensional inhomogeneous distribution of BTX-A. Preliminary in vivo patient results indicated that SF and SE discard artifactual BTX-A detection outside the injection region. The proposed methods contribute to objectivize ultrasound-guided injections, with additional applications, for instance, to monitor injectate spread of local anesthetics.

Management of Anterocapitis and Anterocollis: A Novel Ultrasound Guided Approach Combined with Electromyography for Botulinum Toxin Injection of Longus Colli and Longus Capitis

Chemodenervation of cervical musculature using botulinum neurotoxin (BoNT) is established as the gold standard or treatment of choice for management of Cervical Dystonia (CD). The success of BoNT procedures is measured by improved symptomology while minimizing side effects and is dependent upon many factors including: clinical pattern recognition, identifying contributory muscles, BoNT dosage, and locating and safely injecting target muscles. In patients with CD, treatment of anterocollis (forward flexion of the neck) and anterocaput (anterocapitis) (forward flexion of the head) are inarguably challenging. The longus Colli (LoCol) and longus capitis (LoCap) muscles, two deep cervical spine and head flexor muscles, frequently contribute to these patterns. Localizing and safely injecting these muscles is particularly challenging owing to their deep location and the complex regional anatomy which includes critical neurovascular and other structures. Ultrasound (US) guidance provides direct visualization of the LoCol, LoCap, other cervical muscles and adjacent structures reducing the risks and side effects while improving the clinical outcome of BoNT for these conditions. The addition of electromyography (EMG) provides confirmation of muscle activity within the target muscle. Within this manuscript, we present a technical description of a novel US guided approach (combined with EMG) for BoNT injection into the LoCol and LoCap muscles for the management of anterocollis and anterocaput in patients with CD.

Botulinum Toxin Injection and Electromyography in Patients Receiving Anticoagulants: A Systematic Review

OBJECTIVE

To identify the different practice patterns of botulinum toxin injection (BTX) and electromyography (EMG) in patients receiving anticoagulation and to evaluate the incidence, reporting, and management of bleeding complications and compartment syndrome from BTX and EMG.

LITERATURE SURVEY

Systematic review of relevant clinical studies in PubMed/Medline and Embase databases using key terms from inception to 31 May 2020. All publications in the English language were included without demographic limits.

METHODOLOGY

A comprehensive search was performed to identify all studies addressing BTX and EMG in patients receiving anticoagulants. Two reviewers independently screened the titles, abstracts, and full texts and extracted data based on a set of predefined inclusion and exclusion criteria. All studies that met the inclusion criteria were assigned their respective levels of evidence using the Joanne Briggs Institute (JBI) Level of Evidence for Effectiveness.

SYNTHESIS

Eighteen studies were included in this review of which there were nine studies each on BTX and EMG. The results indicated heterogeneity in the practice patterns of BTX and EMG in patients taking anticoagulants. These included the decision for continuation of anticoagulant, international normalized ratio (INR) results acceptable to practitioners, the modality for procedure guidance, and surveillance of bleeding complications. In addition, there were variations in the description of targeted muscles and description of needle sizes. The overall incidence of bleeding complications and compartment syndrome rates were low.

CONCLUSIONS

Despite the varied practice in anticoagulated patients undergoing BTX or EMG, practitioners should allow periprocedural continuation of anticoagulants, targeting an INR of 2 to 3 while using the smallest needle (25 gauge or smaller) of appropriate length. Some of the evidence on procedural guidance and complication surveillance were weak and more research in these areas is required.

Safe Needle Insertion Locations for Motor Point Injection of the Triceps Brachii Muscle: A Pilot Cadaveric and Ultrasonography Study

Objective

To determine the location of the motor endplate zones (MoEPs) for the three heads of the triceps brachii muscles during cadaveric dissection and estimate the safe injection zone using ultrasonography.

Methods

We studied 12 upper limbs of 6 fresh cadavers obtained from body donations to the medical school anatomy institution in Seoul, Korea. The locations of MoEPs were expressed as the percentage ratio of the vertical distance from the posterior acromion angle to the midpoint of the olecranon process. By using the same reference line as that used for cadaveric dissection, the safe injection zone away from the neurovascular bundle was identified in 6 healthy volunteers via ultrasonography. We identified the neurovascular bundle and its location with respect to the distal end of the humerus and measured its depth from the skin surface.

Results

The MoEPs for the long, lateral, and medial heads were located at a median of 43.8%, 54.8%, and 60.4% of the length of the reference line in cadaver dissection. The safe injection zone of the medial head MoEPs corresponded to a depth of approximately 3.5 cm from the skin surface and 1.4 cm away from the humerus, as determined by sonography.

Conclusion

Correct identification of the motor points for each head of the triceps brachii would increase the precision and efficacy of motor point injections to manage elbow extensor spasticity.

A Functional Approach to Posttraumatic Salivary Fistula Treatment: The Use of Botulinum Toxin

This manuscript highlights key aspects regarding the practical use of botulinum toxin for the conservative nonsurgical treatment of a rarely encountered, but significant posttraumatic complication-the parotid salivary fistula. It adds information to the scarce existing literature on the subject. The authors outline the main differences between postoperative and trauma-related parotid injury regarding salivary fistula treatment. A total of 6 patients with trauma-related salivary fistulas have been treated by Abobotulinum toxin A injections over the course of 5 years. The technique is detailed, describing the doses used in the presence of parenchyma and duct injuries, the location and number of injection points in relation to the wound pattern. The results were favorable, leading to the healing of the salivary fistulas in all patients, with 1 injection session, without additional conservative treatment. In our experience, the use of botulinum toxin is of great benefit for treating salivary fistulas in a traumatic context.

Comment on Ultrasound Guidance for Botulinum Neurotoxin Chemodenervation Procedures. Toxins 2017, 10, 18-Quintessential Use of Ultrasound Guidance for Botulinum Toxin Injections-Muscle Innervation Zone Targeting Revisited

Recently, the importance of targeting structures during botulinum neurotoxin applications has been discussed in a variety of disorders, including spasticity and dystonia. In this respect, the advantages of ultrasound imaging to traditional techniques have been emphasized. We would like underscore the importance of ultrasound guidance, with targeting innervation zone(s) of the over-active muscles to achieve effective clinical outcomes. Additionally, we also clarify the difference between the terms—innervation zone (motor end plate) and motor point—which have been used by the authors as if they were the same. Further, we disagree with the authors about the intramuscular botulinum neurotoxin application techniques i.e., in-plane vs. out-of-plane whereby the former is, for sure, superior.

Indications for neuromuscular ultrasound: Expert opinion and review of the literature

Over the last two decades, dozens of applications have emerged for ultrasonography in neuromuscular disorders. We wanted to measure its impact on practice in laboratories where the technique is in frequent use. After identifying experts in neuromuscular ultrasound and electrodiagnosis, we assessed their use of ultrasonography for different indications and their expectations for its future evolution. We then identified the earliest papers to provide convincing evidence of the utility of ultrasound for particular indications and analyzed the relationship of their date of publication with expert usage. We found that experts use ultrasonography often for inflammatory, hereditary, traumatic, compressive and neoplastic neuropathies, and somewhat less often for neuronopathies and myopathies. Usage significantly correlated with the timing of key publications in the field. We review these findings and the extensive evidence supporting the value of neuromuscular ultrasound. Advancement of the field of clinical neurophysiology depends on widespread translation of these findings.

Evaluating the functional outcomes of ultrasound-guided botulinum toxin type A injections using the Euro-musculus approach for upper limb spasticity treatment in post-stroke patients: an observational study

BACKGROUND

Ultrasound-guided botulinum toxin type A injection is an effective treatment for spasticity. Euro-musculus spasticity approach is a new method for administering injections to the correct point of the correct muscle. The clinical outcomes of this practical approach are not yet available in the literature.

AIM

The purpose of this study was to evaluate the effects on spasticity and the functional outcomes of ultrasound guided botulinum toxin type A injections via the Euro-musculus spasticity approach to treat upper limb spasticity in post-stroke patients.

DESIGN

Observational study.

SETTING

Inpatient post-stroke patients.

POPULATION

Twenty-five post-stroke patients with post-stroke upper limb spasticity were recruited.

METHODS

The ultrasound-guided botulinum toxin type A injections were administered into the spastic target muscles using the Euro-musculus spasticity approach, and all of the patients were enrolled in rehabilitation programs after the injections. This research included the innervation zone and injection site figures and ultrasound images of each muscle in the upper limb. The degree of spasticity was assessed via the Modified Ashworth Scale and the upper limb motor function via the Fugl Meyer Upper Extremity Scale at the baseline and 4 and 12 weeks after the botulinum toxin type A injection.

RESULTS

Significant decreases in the Modified Ashworth Scale scores of the upper limb flexor muscle tone measured 4 and 12 weeks after the botulinum toxin type A injection were found when compared to the baseline scores (P<0.025). When compared with the baseline Fugl Meyer Upper Extremity subgroup scores, the sitting position, wrist and total scores at 4 and 12 weeks were significantly improved (P<0.025). However, only the Fugl Meyer Upper Extremity hand scores were significantly improved 12 weeks after the injection (P<0.025).

CONCLUSIONS

Ultrasound-guided botulinum toxin type A injection via the Euro-musculus spasticity approach is a practical and effective method for administering injections to the correct point of the correct muscle. Ultrasound-guided botulinum toxin type A injections combined with rehabilitation programs decrease spasticity and improve the upper extremity motor functions in stroke patients.

CLINICAL REHABILITATION IMPACT

This new approach for ultrasound-guided botulinum toxin type A injection is very practical and effective method for upper extremity spasticity.