Skip to main content

Accuracy of non-guided versus ultrasound-guided injections in cervical muscles: a cadaver study

Abstract

Introduction

The col-cap concept encouraged neurologists to inject a large group of muscles in the treatment of cervical dystonia. This includes deep muscles such as the obliquus capitis inferior or the semispinalis capitis, and muscles close to vascular or neurological structures such as scalene muscles. Our aim was to determine the accuracy of injections in cervical muscles using ultrasonography (US) or palpation of anatomical landmarks.

Methods

A mix of paint, gelatin and iodized contrast agent was injected in nine pairs of cervical muscles of human cadavers, according to two injection techniques: US-guided and non-guided. The dye was localized on 1 cm-thick, frozen slices.

Results

A total of 102 muscles was injected in the US-guided group (n = 8). The global accuracy was 88.2%. The lowest accuracy was in the OCI (41.7%); trying to avoid the vertebral artery, injections were too medial. A total of 54 muscles was injected in the non-guided group (n = 3). The global accuracy was 48.0%; moreover, some dye was found in four blood vessels. The embalming process produced texture changes, making difficult the palpation of bony landmarks.

Conclusions

Our results indicate that US-guided injections are more accurate than non-guided injections in most cervical muscles.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

References

  1. Reichel G, Stenner A, Jahn A (2009) The phenomenology of cervical dystonia. Fortschr Neurol Psychiatr 77:272–277. https://doi.org/10.1055/s-0028-1109416

    CAS  Article  PubMed  Google Scholar 

  2. Jost WH, Tatu L, Pandey S et al (2020) Frequency of different subtypes of cervical dystonia: a prospective multicenter study according to Col-Cap concept. J Neural Transm 127:45–50. https://doi.org/10.1007/s00702-019-02116-7

    CAS  Article  PubMed  Google Scholar 

  3. Schramm A, Bäumer T, Fietzek U et al (2015) Relevance of sonography for botulinum toxin treatment of cervical dystonia: an expert statement. J Neural Transm 122:1457–1463. https://doi.org/10.1007/s00702-014-1356-2

    CAS  Article  PubMed  Google Scholar 

  4. Fernández-de-Las-Peñas C, Mesa-Jiménez JA, Lopez-Davis A et al (2020) Cadaveric and ultrasonographic validation of needling placement in the obliquus capitis inferior muscle. Musculoskelet Sci Pract 45:102075. https://doi.org/10.1016/j.msksp.2019.102075

    Article  PubMed  Google Scholar 

  5. Kaymak B, Kara M, Gürçay E, Özçakar L (2018) Sonographic guide for botulinum toxin injections of the neck muscles in cervical dystonia. Phys Med Rehabil Clin N Am 29:105–123. https://doi.org/10.1016/j.pmr.2017.08.009

    Article  PubMed  Google Scholar 

  6. Walter U, Dudesek A (1996) Fietzek UM (2018) A simplified ultrasonography-guided approach for neurotoxin injection into the obliquus capitis inferior muscle in spasmodic torticollis. J Neural Transm Vienna Austria 125:1037–1042. https://doi.org/10.1007/s00702-018-1866-4

    Article  Google Scholar 

  7. Mezaki T (2011) Ultrasound-guided injection of botulinum toxin into the obliquus capitis inferior muscle. Basal Ganglia 1:135–136. https://doi.org/10.1016/j.baga.2011.07.002

    Article  Google Scholar 

  8. Mezaki T (2020) Ultrasound-guided botulinum toxin therapy for deep muscles in cervical dystonia. Neurol Clin Neurosci 8:3–10. https://doi.org/10.1111/ncn3.12343

    CAS  Article  Google Scholar 

  9. Hallgren RC, Andary MT, Wyman AJ, Rowan JJ (2008) A standardized protocol for needle placement in suboccipital muscles. Clin Anat N Y N 21:501–508. https://doi.org/10.1002/ca.20660

    Article  Google Scholar 

  10. Ellis H, Logan B, Dixon A, Bowden D (2015) Human sectional anatomy: atlas of body sections, CT and MRI images. https://ebookcentral.proquest.com/lib/exeter/detail.action?docID=1706993

  11. Elliott JM, Cornwall J, Kennedy E et al (2018) Towards defining muscular regions of interest from axial magnetic resonance imaging with anatomical cross-reference: part II—cervical spine musculature. BMC Musculoskelet Disord. https://doi.org/10.1186/s12891-018-2074-y

    Article  PubMed  PubMed Central  Google Scholar 

  12. Hong JS, Sathe GG, Niyonkuru C, Munin MC (2012) Elimination of dysphagia using ultrasound guidance for botulinum toxin injections in cervical dystonia. Muscle Nerve 46:535–539. https://doi.org/10.1002/mus.23409

    Article  PubMed  Google Scholar 

  13. Miyamoto S, Ide T, Takemura N (2010) Risks and causes of cervical cord and medulla oblongata injuries due to acupuncture. World Neurosurg 73:735–741. https://doi.org/10.1016/j.wneu.2010.03.020

    Article  PubMed  Google Scholar 

  14. Chang K-V, Wu W-T, Özçakar L (2018) Ultrasound-guided interventions of the cervical spine and nerves. Phys Med Rehabil Clin N Am 29:93–103. https://doi.org/10.1016/j.pmr.2017.08.008

    Article  PubMed  Google Scholar 

  15. Speelman JD, Brans JW (1995) Cervical dystonia and botulinum treatment: is electromyographic guidance necessary? Mov Disord 10:802. https://doi.org/10.1002/mds.870100619

    CAS  Article  PubMed  Google Scholar 

  16. Haig AJ, Goodmurphy CW, Harris AR et al (2003) The accuracy of needle placement in lower-limb muscles: a blinded study. Arch Phys Med Rehabil 84:877–882. https://doi.org/10.1016/s0003-9993(03)00014-5

    Article  PubMed  Google Scholar 

  17. Boon AJ, Oney-Marlow TM, Murthy NS et al (2011) Accuracy of electromyography needle placement in cadavers: non-guided vs. ultrasound guided. Muscle Nerve 44:45–49. https://doi.org/10.1002/mus.22008

    Article  PubMed  Google Scholar 

  18. Schnitzler A, Roche N, Denormandie P et al (2012) Manual needle placement: accuracy of botulinum toxin A injections. Muscle Nerve 46:531–534. https://doi.org/10.1002/mus.23410

    Article  PubMed  Google Scholar 

  19. Yun JS, Chung MJ, Kim HR et al (2015) Accuracy of needle placement in cadavers: non-guided versus ultrasound-guided. Ann Rehabil Med 39:163–169. https://doi.org/10.5535/arm.2015.39.2.163

    Article  PubMed  PubMed Central  Google Scholar 

  20. Picelli A, Bonetti P, Fontana C et al (2012) Accuracy of botulinum toxin type A injection into the gastrocnemius muscle of adults with spastic equinus: manual needle placement and electrical stimulation guidance compared using ultrasonography. J Rehabil Med 44:450–452. https://doi.org/10.2340/16501977-0970

    Article  PubMed  Google Scholar 

  21. Molloy FM, Shill HA, Kaelin-Lang A, Karp BI (2002) Accuracy of muscle localization without EMG: implications for treatment of limb dystonia. Neurology 58:805–807. https://doi.org/10.1212/wnl.58.5.805

    CAS  Article  PubMed  Google Scholar 

  22. Picelli A, Roncari L, Baldessarelli S et al (2014) Accuracy of botulinum toxin type A injection into the forearm muscles of chronic stroke patients with spastic flexed wrist and clenched fist: manual needle placement evaluated using ultrasonography. J Rehabil Med 46:1042–1045. https://doi.org/10.2340/16501977-1871

    Article  PubMed  Google Scholar 

  23. Ellies M, Laskawi R, Rohrbach-Volland S et al (2002) Botulinum toxin to reduce saliva flow: selected indications for ultrasound-guided toxin application into salivary glands. Laryngoscope 112:82–86. https://doi.org/10.1097/00005537-200201000-00015

    CAS  Article  PubMed  Google Scholar 

  24. Jost WH, Bäumer T, Laskawi R et al (2019) Therapy of Sialorrhea with Botulinum Neurotoxin. Neurol Ther 8:273–288. https://doi.org/10.1007/s40120-019-00155-6

    Article  PubMed  PubMed Central  Google Scholar 

  25. Scott J (1975) Age, sex and contralateral differences in the volumes of human submandibular salivary glands. Arch Oral Biol 20:885–887. https://doi.org/10.1016/0003-9969(75)90071-0

    CAS  Article  PubMed  Google Scholar 

  26. Eaton KJ, Smith HF (2019) Clinical implications of aberrant neurovascular structures coursing through the submandibular gland. PeerJ 7:e7823. https://doi.org/10.7717/peerj.7823

    Article  PubMed  PubMed Central  Google Scholar 

  27. Thiel W (1992) The preservation of the whole corpse with natural color. Ann Anat 174:185–195

    CAS  Article  Google Scholar 

  28. Benkhadra M, Faust A, Ladoire S et al (2009) Comparison of fresh and Thiel’s embalmed cadavers according to the suitability for ultrasound-guided regional anesthesia of the cervical region. Surg Radiol Anat SRA 31:531–535. https://doi.org/10.1007/s00276-009-0477-z

    Article  PubMed  Google Scholar 

  29. Borodic GE, Ferrante R, Pearce LB, Smith K (1994) Histologic assessment of dose-related diffusion and muscle fiber response after therapeutic botulinum A toxin injections. Mov Disord 9:31–39. https://doi.org/10.1002/mds.870090106

    CAS  Article  PubMed  Google Scholar 

  30. Kreisler A, Simonin C, Degardin A et al (2020) Anatomy-guided injections of botulinum neurotoxin in neck muscles: how accurate is needle placement? Eur J Neurol. https://doi.org/10.1111/ene.14415

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

All the authors would like to warmly thank Pr. Wolgang Jost (Parkinson-Klinik Ortenau, Kreuzbergstr. 12, 77709 Wolfach, Germany) for his teaching. His help was essential when we decided to use ultrasonography in the treatment of cervical dystonia.

Funding

This research did not receive any specific funding from agencies or organizations in the public, commercial, or not-for-profit sectors.

Author information

Authors and Affiliations

Authors

Contributions

XD, AK and CG Conceptualization. XD, AK and CG Methodology. AK, with the assistance of CG and XD Injections. CG, AK and XD Data acquisition. AK Statistics. AK Writing—original draft preparation. XD, LD and CG Writing—review and editing. XD and LD Resources. LD Supervision.

Corresponding author

Correspondence to Alexandre Kreisler.

Ethics declarations

Conflicts of interest

Dr. Kreisler reports personal fees from Allergan France, Merz Pharma France, and Ipsen France, outside the submitted work. Dr. Gerrebout has nothing to disclose. Pr. Defebvre has nothing to disclose. Pr. Demondion has nothing to disclose.

Ethical approval

The use of cadavers for research does not require specific approval by the ethics committee.

Informed consent to participate

The cadavers were donated for research and education on human anatomy.

Informed consent for publication

The cadavers were donated for research and education on human anatomy.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Kreisler, A., Gerrebout, C., Defebvre, L. et al. Accuracy of non-guided versus ultrasound-guided injections in cervical muscles: a cadaver study. J Neurol 268, 1894–1902 (2021). https://doi.org/10.1007/s00415-020-10365-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00415-020-10365-w

Keywords

  • Ultrasonography
  • Neck muscles
  • Injection accuracy
  • Cadaver