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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

Bayram Kaymak

¹,

Fevziye Ünsal Malas

^2,*,

Murat Kara

¹,

Arzu Yağız On

³ and

Levent Özçakar

Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara 06100, Turkey

Ankara Physical Medicine and Rehabilitation Training and Research Center, Ankara 06100, Turkey

Department of Physical and Rehabilitation Medicine, Ege University Medical School, İzmir 35100, Turkey

Author to whom correspondence should be addressed.

Toxins 2018, 10(10), 396; https://doi.org/10.3390/toxins10100396

Submission received: 16 March 2018 / Accepted: 14 June 2018 / Published: 28 September 2018

(This article belongs to the Special Issue Muscle Selection for BoNT)

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Abstract

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.

Keywords:

botulinum toxin; innervation zone; ultrasound

Key Contribution: Intramuscular botulinum toxin injections should be applied into the part(s) of a skeletal muscle containing the innervation zone(s) - using ultrasound guided (in-plane) technique.

We have taken an interest in the review paper by Alter and Karp [1], which has been recently published in your journal. While we congratulate the authors for their great effort in drawing attention to the expanding use of ultrasound (US) imaging for various botulinum toxin (BoNT) applications, we wish to put emphasis on particular issues.

First and foremost, although it is well established that US-guided BoNT injections are performed with better accuracy, there is still discussion on which part of the muscle should be the most appropriate target. In this regard, important US guides based on the innervation zone targeted by BoNT injections have been published [2,3,4,5]. Thereby, more effective (better targeting with lower doses) injections have been proposed. Herein, we need to emphasize that the mentioned innervation zones (motor end plate) harboring the neuromuscular junctions are not the motor points that are referred in the paper by Alter and Karp. Instead, the motor point is physiologically described as the area where the muscle contraction can be created via stimulation with a minimal intensity and short duration of electrical stimulation; and anatomically described as the point(s) where the motor nerve enters a muscle [2]. Herewith, these motor points can be appropriate for nerve blocks (e.g., with phenol) rather than chemodenervation with BoNT. Of note, if one aims to perform nerve blocks, selective motor nerve imaging can also be possible with the use of US [6]. This is actually something denied by the authors.

Second, concerning particular muscles, we strongly disagree with the authors regarding tibialis posterior, iliopsoas, and sternocleidomastoid injections. In the former two muscles, the innervation zones are well known to be localized much more proximal [4,7,8], necessitating injections accordingly (Figure 1 and Figure 2). For the latter one, again based on the evidence of innervation zone distribution, latero-medial rather than cranio-caudal injection would be crucial (Video 1). Yet, the innervation zones are shown to be arranged perpendicular to the muscle fibers [5].

Third, the authors mention that the out-of-plane technique is sometimes more practical and can be preferred for different reasons [1]. However, to follow the precise localization of the needle (tip) either during insertion or while seeding the BoNT toxin through the innervation zones, one needs to continuously follow the aforementioned details of the procedure [9]. This is also paramount for avoiding injury to nearby vital structures.

Last, but not least, the authors refer to a previously published guide and state that high volume injections would be effective in the proximal upper extremity muscles [1]. Herein, we need to mention the contrary i.e., using lower volumes/doses could definitely be more reasonable (cost-effective and with less side effects) as long as the injections target the innervation zone(s) of each/every muscle.

Supplementary Materials

The following are available online at https://www.mdpi.com/2072-6651/10/10/396/s1, Video S1: Scm injection.

Author Contributions

Conceptualization. B.K., F.U.M., M.K.; Writing-Original Draft Preparation, F.U.M., B.K., M.K.; Writing-Review & Editing, L.Ö, B.K., A.Y.O; Visualization, M.K., L.Ö.; Supervision, A.Y.O.

Funding

This research received no external funding.

Conflicts of Interest

The authors declare no conflict of interest.

References

Alter, K.E.; Karp, B. Ultrasound guidance for botulinum neurotoxin chemodenervation procedures. Toxins 2018, 10, 18. [Google Scholar] [CrossRef] [PubMed]
Kaymak, B.; Kara, M.; Yağiz On, A.; Soylu, A.R.; Özçakar, L. Innervation zone targeted botulinum toxin injections. Eur. J. Phys. Rehabil. Med. 2018, 54, 100–109. [Google Scholar] [PubMed]
Kara, M.; Kaymak, B.; Ulaşli, A.M.; Tok, F.; Öztürk, G.T.; Chang, K.V.; Hsiao, M.Y.; Hung, C.Y.; Yağiz On, A.; Özçakar, L. Sonographic guide for botulinum toxin injections of the upper limb: Euro-musculus/USPRM spasticity approach. Eur. J. Phys. Rehabil. Med. 2018, 54, 486–498. [Google Scholar]
Kaymak, B.; Kara, M.; Tok, F.; Ulasli, A.M.; Öztürk, G.T.; Chang, K.V.; Hsiao, M.Y.; Hung, C.Y.; Yağiz On, A.; Özçakar, L. Sonographic guide for botulinum toxin injections of the lower limb: Euro-musculus/USPRM spasticity approach. Eur. J. Phys. Rehabil. Med. 2018, 54, 469–485. [Google Scholar]
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Kaymak, B.; Kara, M.; Gürçay, E.; Aydın, G.; Ozçakar, L. Selective peripheral neurolysis using ultrasound imaging: A novel approach in the treatment of spasticity. Eur. J. Phys. Rehabil. Med. 2018. [Google Scholar] [CrossRef]
Yi, K.H.; Rha, D.W.; Lee, S.C.; Cong, L.; Lee, H.J.; Lee, Y.W.; Kim, H.J.; Hu, K.S. Intramuscular nerve distribution pattern of ankle invertor muscles in human cadaver using Sihler stain. Muscle Nerve 2016, 53, 724–727. [Google Scholar] [CrossRef] [PubMed]
Van Campenhout, A.; Hubens, G.; Fagard, K.; Molenaers, G. Localization of motor nerve branches of the human psoas muscle. Muscle Nerve 2010, 42, 202–207. [Google Scholar] [CrossRef] [PubMed]
Kara, M.; Sekizkardes, M.; Kaymak, B.; Aydin, G.; Özçakar, L. Two-step ultrasound guidance for needle electromyography and botulinum toxin injections in cervical dystonia. Am. J. Phys. Med. Rehabil. 2018, submitted. [Google Scholar]

Figure 1. Ultrasound imaging (axial view) for psoas major muscle. SP: Spinous process; F: Facet joint; M: Multifidus; LL: Longissimus lumborum; IL: Iliocostalis lumborum; QL: Quadratus lumborum.

Figure 2. Ultrasound imaging (axial view) for tibialis posterior muscle. TA: Tibialis anterior; T: Tibia; F: Fibula; EDL: Extensor digitorum longus; FL: Fibularis longus; a: Artery; n: Nerve; *: Interosseous membrane.

© 2018 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).

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MDPI and ACS Style

Kaymak, B.; Malas, F.Ü.; Kara, M.; On, A.Y.; Özçakar, L. 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. Toxins 2018, 10, 396. https://doi.org/10.3390/toxins10100396

AMA Style

Kaymak B, Malas FÜ, Kara M, On AY, Özçakar L. 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. Toxins. 2018; 10(10):396. https://doi.org/10.3390/toxins10100396

Chicago/Turabian Style

Kaymak, Bayram, Fevziye Ünsal Malas, Murat Kara, Arzu Yağız On, and Levent Özçakar. 2018. "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" Toxins 10, no. 10: 396. https://doi.org/10.3390/toxins10100396

APA Style

Kaymak, B., Malas, F. Ü., Kara, M., On, A. Y., & Özçakar, L. (2018). 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. Toxins, 10(10), 396. https://doi.org/10.3390/toxins10100396

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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

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