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Aradi S, Hauser RA. Current use of neurotoxins for alleviating symptoms of cervical dystonia. Expert Rev Neurother 2024; 24:787-797. [PMID: 39049547 DOI: 10.1080/14737175.2024.2368638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 06/12/2024] [Indexed: 07/27/2024]
Abstract
INTRODUCTION Cervical dystonia (CD) causes involuntary movements and postures of the head, neck, and shoulders, as well as nonmotor symptoms including pain, mood, and sleep dysfunction, and impacts quality of life. The first-line treatment for CD is botulinum neurotoxin (BoNT) injections. AREAS COVERED The clinical presentation and diagnosis of CD, as well as where BoNT resides in the treatment landscape, is reviewed first. Next, the mechanism of action and the pharmacological differences in the available preparations of BoNT products are explained. The evidence base for motor and nonmotor efficacy and safety of the available BoNT formulations is reviewed, with attention to duration of benefit as a driver of patient satisfaction. Practical determinants of BoNT efficacy are reviewed including muscle selection, accurate muscle injection, factors related to poor or deteriorating response, and immunogenicity. EXPERT OPINION BoNT represents a significant advancement in the treatment of CD. More accurate diagnosis, muscle selection and targeting, and dosing can improve outcomes with existing BoNT formulations. Further refinement of BoNT potency, duration of action, safety, and immunogenicity will help reduce unmet needs in the magnitude and duration of benefit. Additional validation of DBS and MRI-guided focused ultrasound may expand options for patients with toxin nonresponse.
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Affiliation(s)
- Stephen Aradi
- Department of Neurology, Parkinson's Foundation Center of Excellence, University of South Florida, TampaFLUSA
| | - Robert A Hauser
- Department of Neurology, Parkinson's Foundation Center of Excellence, University of South Florida, TampaFLUSA
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Heslot C, Khan O, Schnitzler A, Haldane C, David R, Reebye R. Enhancing Botulinum Toxin Injection Precision: The Efficacy of a Single Cadaveric Ultrasound Training Intervention for Improved Anatomical Localization. Toxins (Basel) 2024; 16:304. [PMID: 39057944 PMCID: PMC11281316 DOI: 10.3390/toxins16070304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 05/25/2024] [Accepted: 06/26/2024] [Indexed: 07/28/2024] Open
Abstract
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.
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Affiliation(s)
- Camille Heslot
- Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress (CANOSC), Kingston, ON K7K 1Z6, Canada
- Faculty of Medicine, Paris Cité University, 75006 Paris, France
- Department of Physical Medicine and Rehabilitation, GH St Louis Lariboisière F. Widal, 75010 Paris, France
| | - Omar Khan
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress (CANOSC), Kingston, ON K7K 1Z6, Canada
- Hotel Dieu Shaver Health and Rehabilitation Centre, St. Catharines, ON L2T 4C2, Canada
| | - Alexis Schnitzler
- Faculty of Medicine, Paris Cité University, 75006 Paris, France
- Department of Physical Medicine and Rehabilitation, GH St Louis Lariboisière F. Widal, 75010 Paris, France
| | - Chloe Haldane
- Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress (CANOSC), Kingston, ON K7K 1Z6, Canada
| | - Romain David
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress (CANOSC), Kingston, ON K7K 1Z6, Canada
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86000 Poitiers, France
- Department of Physical Medicine and Rehabilitation, Poitiers University Hospital, 86000 Poitiers, France
| | - Rajiv Reebye
- Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress (CANOSC), Kingston, ON K7K 1Z6, Canada
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Chang SY, Lim HY, Kim SH, Choi JW, Nam YS, Lee JI. Surface anatomy and levator scapulae muscle injection: A cadaveric investigation. Medicine (Baltimore) 2024; 103:e38598. [PMID: 38905373 PMCID: PMC11191861 DOI: 10.1097/md.0000000000038598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Accepted: 05/24/2024] [Indexed: 06/23/2024] Open
Abstract
Accurate detection of the levator scapulae muscle is critical for effective diagnostic and therapeutic interventions. The commonly used surface anatomy approach has not been validated and is less accurate than ultrasound-guided techniques. Therefore, we determined the needle insertion point for the levator scapulae using a new technique based on the anatomy of the scapula. This investigation used 15 fresh-frozen cadavers to explore the relationship between the acromial angle and medial tip of the scapular spine (O) of the scapular spine. Based on the x-axis (the distance [L] from Point O to point acromial angle) and the y-axis perpendicular to the x-axis passing through Point O, the barycentric coordinates were determined through the intersections of each axis and the superior angle of the scapula with the levator scapulae. Various ratios involving the established distance L) were ascertained, we compared the measurements and ratios between the male and female groups, and the accuracy of the new technique was compared with the conventional technique. The optimal site of the new technique was within 6 to 7% of distance L on the x-axis and 42 to 44% of distance L on the y-axis. This technique was significantly more accurate than the conventional technique (P = .006). Although ultrasound allows for accurate injections via real-time visualization, its unavailability in some cases highlights the importance of understanding surface anatomy landmarks. Our new technique, based on the anatomy of the scapula and relative measurements, is more accurate than the conventional technique. This should enable more precise detection of the levator scapulae for accurate and efficient diagnostic and therapeutic procedures.
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Affiliation(s)
- So-Youn Chang
- Department of Rehabilitation Medicine, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hee Young Lim
- Department of Rehabilitation Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang-Hyun Kim
- Catholic Institute for Applied Anatomy, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jung-Woo Choi
- Catholic Institute for Applied Anatomy, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yong-Seok Nam
- Department of Anatomy, College of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Jong In Lee
- Department of Rehabilitation Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Marques A, Rieu I, Durif F. Botulinum Toxin for Isolated or Essential Head Tremor. Reply. N Engl J Med 2024; 390:384. [PMID: 38265658 DOI: 10.1056/nejmc2314018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Affiliation(s)
- Ana Marques
- Centre Hospitalier Universitaire Clermont-Ferrand, Clermont-Ferrand, France
| | - Isabelle Rieu
- Centre Hospitalier Universitaire Clermont-Ferrand, Clermont-Ferrand, France
| | - Franck Durif
- Centre Hospitalier Universitaire Clermont-Ferrand, Clermont-Ferrand, France
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Toliopoulos A. In-Plane Ultrasound-Guided Botulinum Toxin Injection to Lumbrical and Interosseus Upper Limb Muscles: Technical Report. Cureus 2023; 15:e45073. [PMID: 37842408 PMCID: PMC10568236 DOI: 10.7759/cureus.45073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2023] [Indexed: 10/17/2023] Open
Abstract
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.
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Affiliation(s)
- Alexandros Toliopoulos
- Neurology, Rehabilitation and Sports Medicine Clinic Evosmos, Thessaloniki, GRC
- Sports Medicine, Rehabilitation and Sports Medicine Clinic Evosmos, Thessaloniki, GRC
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Erro R, Picillo M, Pellecchia MT, Barone P. Improving the Efficacy of Botulinum Toxin for Cervical Dystonia: A Scoping Review. Toxins (Basel) 2023; 15:391. [PMID: 37368692 DOI: 10.3390/toxins15060391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/18/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023] Open
Abstract
Cervical dstonia (CD) is a chronic disorder with a significant detrimental impact on quality of life, requiring long-term treatment. Intramuscular injections of botulinum neurotoxin (BoNT) every 12 to 16 weeks have become the first-line option for CD. Despite the remarkable efficacy of BoNT as a treatment for CD, a significantly high proportion of patients report poor outcomes and discontinue the treatment. The reasons that drive sub-optimal response or treatment failure in a proportion of patients include but are not limited to inappropriate muscle targets and/or BoNT dosing, improper method of injections, subjective feeling of inefficacy, and the formation of neutralizing antibodies against the neurotoxin. The current review aims to complement published research focusing on the identification of the factors that might explain the failure of BoNT treatment in CD, highlighting possible solutions to improve its outcomes. Thus, the use of the new phenomenological classification of cervical dystonia known as COL-CAP might improve the identification of the muscle targets, but more sensitive information might come from the use of kinematic or scintigraphic techniques and the use of electromyographic or ultrasound guidance might ensure the accuracy of the injections. Suggestions are made for the development of a patient-centered model for the management of cervical dystonia and to emphasize that unmet needs in the field are to increase awareness about the non-motor spectrum of CD, which might influence the perception of the efficacy from BoNT injections, and the development of dedicated rehabilitation programs for CD that might enhance its effectiveness.
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Affiliation(s)
- Roberto Erro
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Neuroscience Section, University of Salerno, Via Allende 43, 84081 Baronissi, SA, Italy
| | - Marina Picillo
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Neuroscience Section, University of Salerno, Via Allende 43, 84081 Baronissi, SA, Italy
| | - Maria Teresa Pellecchia
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Neuroscience Section, University of Salerno, Via Allende 43, 84081 Baronissi, SA, Italy
| | - Paolo Barone
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Neuroscience Section, University of Salerno, Via Allende 43, 84081 Baronissi, SA, Italy
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Asimakidou E, Sidiropoulos C. A Bayesian Network Meta-Analysis and Systematic Review of Guidance Techniques in Botulinum Toxin Injections and Their Hierarchy in the Treatment of Limb Spasticity. Toxins (Basel) 2023; 15:toxins15040256. [PMID: 37104194 PMCID: PMC10145352 DOI: 10.3390/toxins15040256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 03/22/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
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.
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Kreisler A, Djelad S, Simonin C, Baille G, Mutez E, Degardin A, Defebvre L, Labreuche J, Cailliau E, Duhamel A. Does ultrasound-guidance improve the outcome of botulinum toxin injections in cervical dystonia? Rev Neurol (Paris) 2021; 178:591-602. [PMID: 34916042 DOI: 10.1016/j.neurol.2021.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 10/29/2021] [Accepted: 11/02/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Ultrasound-guided injections of botulinum neurotoxin in cervical dystonia have a number of theoretical advantages. However, their action has never been compared to that of non-guided injections. The objectives of the study were to compare the outcome of botulinum neurotoxin type A treatment in patients with idiopathic, focal cervical dystonia, according to two methods: inspection and palpation of anatomical landmarks (non-guided group) or ultrasound guidance (ultrasound-guided group). METHODS We included consecutive patients in this single-center, prospective, real-life, non-randomized study. The outcomes were evaluated one month after the injections: Cervical Dystonia Impact Profile 58 (main outcome), Toronto Western Spasmodic Torticollis Rating Scale-2 (pain and disability subscores), Toronto Western Spasmodic Torticollis Rating Scale-PSYCH, patient-rated Clinical Global Impression - Improvement and adverse events. We used propensity score methods for statistical analysis; ten predefined confounding factors were used to build the propensity score. RESULTS Sixty-three patients were included in the non-guided group, and 60 other patients in the ultrasound-guided group. We found no difference in main and secondary outcomes between the two study groups. CONCLUSION This is the first direct comparison between ultrasound-guided and non-guided botulinum neurotoxin type A injections in patients with cervical dystonia. We hypothesize that ultrasound guidance made it possible to obtain the same results in the most severe (or the most demanding) patients as in the best responders. Further studies are still needed to assess the impact of botulinum neurotoxin injections into deep cervical muscles.
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Affiliation(s)
- A Kreisler
- Movement disorders department, CHU Lille, 59000 Lille, France.
| | - S Djelad
- Movement disorders department, CHU Lille, 59000 Lille, France.
| | - C Simonin
- Movement disorders department, CHU Lille, 59000 Lille, France; University Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, 59000 Lille, France.
| | - G Baille
- Movement disorders department, CHU Lille, 59000 Lille, France; Hôpital Delafontaine, Neurology Department, 93200 St Denis, France.
| | - E Mutez
- Movement disorders department, CHU Lille, 59000 Lille, France; University Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, 59000 Lille, France.
| | - A Degardin
- Movement disorders department, CHU Lille, 59000 Lille, France.
| | - L Defebvre
- Movement disorders department, CHU Lille, 59000 Lille, France.
| | - J Labreuche
- University Lille, CHU Lille, U2694 METRICS, 59000 Lille, France.
| | - E Cailliau
- University Lille, CHU Lille, U2694 METRICS, 59000 Lille, France.
| | - A Duhamel
- University Lille, CHU Lille, U2694 METRICS, 59000 Lille, France.
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The Role of Ultrasound for the Personalized Botulinum Toxin Treatment of Cervical Dystonia. Toxins (Basel) 2021; 13:toxins13050365. [PMID: 34065541 PMCID: PMC8161276 DOI: 10.3390/toxins13050365] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 05/17/2021] [Accepted: 05/19/2021] [Indexed: 12/12/2022] Open
Abstract
The visualization of the human body has frequently been groundbreaking in medicine. In the last few years, the use of ultrasound (US) imaging has become a well-established procedure for botulinum toxin therapy in people with cervical dystonia (CD). It is now undisputed among experts that some of the most relevant muscles in this indication can be safely injected under visual US guidance. This review will explore the method from basic technical considerations, current evidence to conceptual developments of the phenomenology of cervical dystonia. We will review the implications of introducing US to our understanding of muscle function and anatomy of common cervical dystonic patterns. We suggest a flow chart for the use of US to achieve a personalized treatment of people with CD. Thus, we hope to contribute a resource that is useful in clinical practice and that stimulates the ongoing development of this valuable technique.
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Morphological characteristics of the posterior neck muscles and anatomical landmarks for botulinum toxin injections. Surg Radiol Anat 2021; 43:1235-1242. [PMID: 33847773 DOI: 10.1007/s00276-021-02745-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 03/29/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Cervical dystonia is a common movement disorder for which botulinum toxin (BoNT) is the first choice treatment. Injecting the specific neck muscles can be challenging because of their thin morphology and deep locations. We, therefore, designed a study to investigate the locations of the posterior neck muscles to help the physician predict the locations of the targeted neck muscles and to protect the vertebral vessels from injury during deep injections. METHODS The posterior neck region was divided into four quadrants by imaginary lines passing vertically and transversely through the spinous process of C2 vertebra (C2sp). The thicknesses and depth of the posterior neck muscles were measured in ten formaldehyde-fixed adult male cadavers. These muscles were located and a projection of them was drawn on the neck. Using the measurements, colored latex in place of BoNT was injected into them in one cadaver. The cadaver was dissected to investigate whether the muscles were colored. RESULTS 2 cm above the C2sp, trapezius, splenius capitis (SPC) and semispinalis capitis (SSC) were colored at depths of 10.70 mm, 11.88 mm and 15.91 mm, respectively. 2 cm below the C2sp, the trapezius, SPC and SSC were colored at depths of 20.89 mm, 23.25 mm and 27.63 mm, respectively. The posterior neck muscles were had taken up their assigned colors when they were injected according to the results obtained in this study. The vertebral vessels were not colored. CONCLUSIONS Although BoNT injection into the posterior neck muscles is challenging, we think that it can be practically and safely applied using the measurements obtained in this study.
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