Ultrasound-guided injection of botulinum toxin A in the treatment of iliopsoas spasticity

Pictorial Essay on Ultrasound and Magnetic Resonance Imaging of Paraspinal Muscles for Myofascial Pain Syndrome

The paraspinal muscles of the cervical, thoracic, and lumbar spine are important pain generators because muscle strains or myofascial pain syndrome caused by trigger points are common during clinical practice. Ultrasonography is the most convenient imaging tool for evaluating these muscles due to its advantages, such as providing good delineation of soft tissues, easy accessibility, and zero radiation. Additionally, ultrasound can serve as a useful guiding tool for paraspinal muscle intervention to prevent inadvertent injuries to vital axial neurovascular structures. This pictorial essay presents ultrasound scanning protocols for the paraspinal and other associated muscles as well as a discussion of their clinical relevance. Axial magnetic resonance imaging has also been used to elucidate reciprocal anatomy. In conclusion, ultrasound imaging proves to be a valuable tool that facilitates the differentiation of individual paraspinal muscles. This capability significantly enhances the precision of interventions designed to address myofascial pain syndrome.

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.

The Emerging Era of Interventional Imaging in Rheumatology: An Overview During the Coronavirus Disease-2019 (COVID-19) Pandemic

Imaging has long been taking its place in the diagnosis, monitor, and prognosis of rheumatic diseases. It plays a vital role in the appraisal of treatment. Key progress in the clinical practice of rheumatology is the innovation of advanced imaging modalities; such as musculoskeletal ultrasound (MSUS), computerized tomography (CT) and magnetic resonance imaging (MRI). These modalities introduced a promising noninvasive method for visualizing bone and soft tissues to enable an improved diagnosis. The use of MSUS in rheumatology is considered a landmark in the evolution of the specialty and its ease of use and many applications in rheumatic diseases make it a forerunner instrument in the practice. The use of MSUS among rheumatologists must parallel the development rate of the excellence revealed in the specialty. Moreover, innovative interventional imaging in rheumatology (III-R) is gaining fame and key roles in the near future for a comprehensive management of rheumatic diseases with precision. This review article throws light on the emergence of these robust innovations that may reshape the guidelines and practice in rheumatology, in particular, efforts to enhance best practice during the coronavirus disease 2019 (COVID-19) pandemic are endorsed.

Multiphysics Modeling and Simulation of Subcutaneous Injection and Absorption of Biotherapeutics: Model Development

PURPOSE

Many monoclonal antibodies (mAbs) are administered via subcutaneous (SC) injection. Local transport and absorption kinetics and mechanisms, however, remain poorly understood. A multiphysics computational model was developed to simulate the injection and absorption processes of a protein solution in the SC tissue.

METHODS

Quantitative relationships among tissue properties and transport behaviors of an injected solution were described by respective physical laws. SC tissue was treated as a 3-dimensional homogenous, poroelastic medium, in which vasculatures and lymphatic vessels were implicitly treated. Tissue deformation was considered, and interstitial fluid flow was modeled by Darcy's law. Transport of the drug mass was described based on diffusion and advection, which was integrated with tissue mechanics and interstitial fluid dynamics.

RESULTS

Injection and absorption of albumin and IgG solutions were simulated. Upon injection, a sharp rise in tissue pressure, porosity, and fluid velocity could be observed at the injection tip. Largest tissue deformation appeared at the model surface. Transport of drug mass out of the injection zone was minimal. Absorption by local lymphatics was found to last several weeks.

CONCLUSIONS

A bottom-up method was developed to simulate drug transport and absorption of protein solutions in skin tissue base on physical principles. The results appear to match experimental observations.

Image quality of hip MR arthrography with intra-articular injection of hyaluronic acid versus gadolinium-based contrast agent in patients with femoroacetabular impingement

OBJECTIVE

To compare image quality of magnetic resonance arthrography (MRA) of the hip with intra-articular injection of high-viscosity hyaluronic acid (HA-MRA) versus Gd-based contrast agent (Gd-MRA) in patients with femoroacetabular impingement (FAI).

MATERIALS AND METHODS

Design: single-centre, observational, retrospective, inter-individual, and cross-sectional. FAI patients who underwent HA-MRA (3 mL of high-viscosity HA plus 17 mL of saline) were compared with 37 age- and sex-matched FAI patients who underwent Gd-MRA (20 mL of 2 mmol/L solution of gadopentetate dimeglumine). Two independent blinded radiologists assessed image quality for all sequences (two-dimensional proton density, non-fat-sat axial, fat-sat coronal and sagittal; three-dimensional dual-echo steady state), using a 5-point Likert scale considering separately labrum, cartilage, round ligament, transverse ligament, and capsule. Pearson χ² and Cohen κ were used.

RESULTS

The HA-MRA group was composed of 37 patients (23 males, 14 females; median age 38 years), the Gd-MRA group of 37 patients (21 males, 16 females; median age 38 years), without significant difference for age (p = 0.937) and sex (p = 0.636). Image quality did not differ between the two readers for any structure: labrum (p ≥ 0.340), cartilage (p ≥ 0.198), round ligament (p ≥ 0.255), transverse ligament (p ≥ 0.806), and capsule (p ≥ 0.314). Inter-reader agreement (κ) ranged from 0.785 to 1.000.

CONCLUSIONS

HA-MRA provided an image quality not significantly different from that of Gd-MRA. This may open the possibility of combining MRA and viscosupplementation in one single procedure.

Rotator cuff calcific tendinopathy: from diagnosis to treatment

Rotator cuff calcific tendinopathy (RCCT) is a very common condition caused by the presence of calcific deposits in the rotator cuff (RC) or in the subacromial-subdeltoid (SASD) bursa when calcification spreads around the tendons. The pathogenetic mechanism of RCCT is still unclear. It seems to be related to cell-mediated disease in which metaplastic transformation of tenocytes into chondrocytes induces calcification inside the tendon of the RC. RCCT is a frequent finding in the RC that may cause significant shoulder pain and disability. It can be easily diagnosed with imaging studies as conventional radiography (CR) or ultrasound (US). Conservative management of RCCT usually involves rest, physical therapy, and oral NSAIDs administration. Imaging-guided treatments are currently considered minimally-invasive, yet effective methods to treat RCCT with about 80% success rate. Surgery remains the most invasive treatment option in chronic cases that fail to improve with other less invasive approaches. (www.actabiomedica.it)

Ultrasound-guided botulinum toxin injections in neurology: technique, indications and future perspectives

Botulinum toxin (BT) therapy is used in neurology to treat muscle hyperactivity disorders including dystonia, spasticity, cerebral palsy, hemifacial spasms and re-innervation synkinesias as well as exocrine gland hyperactivity disorders. To increase its therapeutic effect and to decrease adverse effects in adjacent tissues, exact BT placement is important. Ultrasonography (US) allows non-invasive, real-time imaging of muscular and glandular tissues and their surrounding structures. It can visualize, guide, and standardize the entire procedure of BT application. Small randomized studies suggest that US-guidance can improve therapeutic efficacy and reduce adverse effects of BT therapy when compared to conventional placement. US-guidance should be used in forearm muscles when functionality is important, and in selected leg muscles. It may be used for targeting distinct neck muscles in cervical dystonia. It is helpful for targeting the salivary glands. Here we review the technique, indications and future developments of US-guidance for BT injection in neurological disorders.

The role of ultrasonography in the assessment of peri-prosthetic hip complications

PURPOSE

Total hip arthroplasty (THA) is a widespread option for treating hip osteoarthritis. Peri-prosthetic complications after THA represent a common event influencing patient outcome and costs. The purpose of this paper is to report the use of ultrasonography (US) to detect peri-prosthetic complications in symptomatic patients who underwent THA.

METHODS

We retrospectively reviewed the records of patients with THA who underwent imaging evaluation between January 2009 and December 2012 at two different institutions. We evaluated the presence/absence of superficial and/or deep peri-prosthetic collections as well as the presence/absence of a cutaneous sinus tract. For patients who underwent both MRI and US, a concordance correlation analysis between US and MR findings was performed.

RESULTS

In the reference period, 532 symptomatic patients (mean age ± standard deviation 74 ± 12 years) underwent X-ray and MRI examinations for suspected peri-prosthetic complications. Among them, 111 (20.9 %) underwent also US. Overall, 108 patients underwent both US and MRI. US findings included 67 superficial collections, 48 subcutaneous fistulas, 74 deep peri-prosthetic collections. Twenty-four patients had solid, mass-like peri-prosthetic collections. In 11 patients, no peri-prosthetic complications were seen. MRI findings included 68 superficial collections, 49 subcutaneous fistulas, 79 deep peri-prosthetic collections. Twenty-four patients had solid, mass-like peri-prosthetic collections. In four patients, no peri-prosthetic complications were seen. Concordance analysis between US and MRI findings showed almost perfect agreement (k ≥ 0.89).

CONCLUSION

US is an efficient and practical imaging modality to evaluate peri-prosthetic complications in patients with THA, being almost comparable to MRI in detecting and characterizing these complications.

Computerized-Aid Medical Training

The application of new technologies in training environments allows the development of new teaching modalities that enable knowledge and ability acquisition in healthcare professionals. Simulation has proven to be an effective method to favor and improve learning as well as to attain the necessary skills to perform a specific technique with greater reliability and security for the patient. We present a new tool or technological development in medical training, through an ultrasound simulator, valid for the knowledge and necessary ability acquisition in the proper infiltration of botulinum toxin guided by ultrasound. This tool benefits from the advantages that new technologies bring when applied in medical training, offering a virtual setting, comfortable and accessible, that does not require the user to move or have access to an ultrasound machine, allowing ultrasound explorations without the existence of a real patient.

Bedside ultrasonography of musculoskeletal complications in brain injured patients

INTRODUCTION

The aim of this study was to evaluate the role of bedside ultrasonography (US) in early diagnosis of musculoskeletal complications (MSC) of acquired brain injuries, to describe its incidence and US features in a neurorehabilitation setting.

MATERIALS AND METHODS

All 163 patients admitted in tertiary-level neurorehabilitation unit with diagnosis of stroke or severe brain injury (SBI), with symptoms or signs of musculoskeletal pathology, underwent bedside US.

RESULTS

MSC were diagnosed in 51.5%. In 86.9% US clarified diagnosis and/or modified therapeutic approach. Shoulder pain was observed in 27.6%. US showed a shoulder subluxation in 73.3% and a frozen shoulder in 8.8% of painful shoulders. In all the cases rotator cuff abnormalities were noted. Wrist-hand syndrome was observed in 29.4%. US showed mild effusion in wrist joints and tendon sheaths and subcutaneous edema without significant vascularity. Neurogenic heterotopic ossification was observed in 1.8%. US demonstrated the "zone phenomenon" or heterogeneously hypoechoic mass with low resistance vessels within the lesions. Contractures and spasticity were observed in 18.4%. US allowed reliable guidance for Botulinum toxin A injection. Relapsing osteoarthritis and acute arthritis were diagnosed in 15.3% and 7.3% respectively. Patients with MSC had lower Functional Independence Measurement (FIM) and Katz index scores in discharge (p < 0.04 and p < 0.0294 respectively) and more length of hospital stay (p = 0.0024).

DISCUSSION

Musculoskeletal pathology frequently complicates the course of acquired brain injuries and it delays functional recovery. Bedside US is a cheap and sensitive diagnostic tool and it can aid clinicians to define diagnosis and to choose therapeutic approach.