Accuracy of Ultrasound-Guided and Non-guided Botulinum Toxin Injection Into Neck Muscles Involved in Cervical Dystonia: A Cadaveric Study.

OBJECTIVE: To compare the accuracy of ultrasound-guided and non-guided botulinum toxin injections into the neck muscles involved in cervical dystonia. METHODS: Two physicians examined six muscles (sternocleidomastoid, upper trapezius, levator scapulae, splenius capitis, scalenus anterior, and scalenus medius) from six fresh cadavers. Each physician injected ultrasound-guided and non-guided injections to each side of the cadaver's neck muscles, respectively. Each physician then dissected the other physician's injected muscle to identify the injection results. For each injection technique, different colored dyes were used. Dissection was performed to identify the results of the injections. The muscles were divided into two groups based on the difficulty of access: sternocleidomastoid and upper trapezius muscles (group A) and the levator scapulae, splenius capitis, scalenus anterior, and scalenus medius muscles (group B). RESULTS: The ultrasound-guided and non-guided injection accuracies of the group B muscles were 95.8% and 54.2%, respectively (p<0.001), while the ultrasound-guided and non-guided injection accuracies of the group A muscles were 100% and 79.2%, respectively (p<0.05). CONCLUSION: Ultrasound-guided botulinum toxin injections into inaccessible neck muscles provide a higher degree of accuracy than non-guided injections. It may also be desirable to consider performing ultrasound-guided injections into accessible neck muscles.

Spinal Accessory Nerve Injury Induced by Manipulation Therapy: A Case Report.

Spinal accessory nerve (SAN) injury mostly occurs during surgical procedures. SAN injury caused by manipulation therapy has been rarely reported. We present a rare case of SAN injury associated with manipulation therapy showing scapular winging and droopy shoulder. A 42-year-old woman visited our outpatient clinic complaining of pain and limited active range of motion (ROM) in right shoulder and scapular winging after manipulation therapy. Needle electromyography and nerve conduction study suggested SAN injury. Physical therapy (PT) three times a week for 2 weeks were prescribed. After a total of 6 sessions of PT and modality, the patient reported that the pain was gradually relieved during shoulder flexion and abduction with improved active ROM of shoulder. Over the course of 2 months follow-up, the patient reported almost recovered shoulder ROM and strength as before. She did not complain of shoulder pain any more.

Botulinum Toxin for Central Neuropathic Pain.

Botulinum toxin (BTX) is widely used to treat muscle spasticity by acting on motor neurons. Recently, studies of the effects of BTX on sensory nerves have been reported and several studies have been conducted to evaluate its effects on peripheral and central neuropathic pain. Central neuropathic pain includes spinal cord injury-related neuropathic pain, post-stroke shoulder pain, multiple sclerosis-related pain, and complex regional pain syndrome. This article reviews the mechanism of central neuropathic pain and assesses the effect of BTX on central neuropathic pain.

Reference Value for Infrapatellar Branch of Saphenous Nerve Conduction Study: Cadaveric and Clinical Study.

OBJECTIVE: To determine the optimal stimulation and recording site for infrapatellar branch of saphenous nerve (IPBSN) conduction studies by a cadaveric study, and to confirm that obtained location is practically applicable to healthy adults. METHODS: Twelve lower limbs from six cadavers were studied. We defined the optimal stimulation site as the point IPBSN exits the sartorius muscle and the distance or ratio were measured on the X- and Y-axis based on the line connecting the medial and lateral poles of the patella. We defined the optimal recording site as the point where the terminal branch met the line connecting inferior pole of patella and tibial tuberosity, and measured the distance from the inferior pole. Also, nerve conduction studies were performed with obtained location in healthy adults. RESULTS: In optimal stimulation site, the mean value of X-coordinate was 55.50±6.10 mm, and the ratio of the Y-coordinate to the thigh length was 25.53%±5.40%. The optimal recording site was located 15.92±1.83 mm below the inferior pole of patella. In our sensory nerve conduction studies through this location, mean peak latency was 4.11±0.30 ms and mean amplitude was 4.16±1.49 µV. CONCLUSION: The optimal stimulation site was located 5.0-6.0 cm medial to medial pole of the patella and 25% of thigh length proximal to the X-axis. The optimal recording site was located 1.5-2.0 cm below inferior pole of patella. We have also confirmed that this location is clinically applicable.

Accuracy of Ultrasound-Guided and Non-ultrasound-Guided Botulinum Toxin Injection Into Cadaver Salivary Glands.

OBJECTIVE: To compare the accuracy of ultrasound (US)-guided and non-US-guided botulinum toxin (BTX) injection into the salivary glands (parotid and submandibular glands) of cadavers. METHODS: Two rehabilitation physician injected dye into three sites in the salivary glands (two sites in the parotid gland and one site in the submandibular gland) on one side of each cadaver (one was injected on the right side, while the other was injected on the left side), using either a non-US-guided injection procedure based on superficial landmarks or a US-guided procedure. Orange dye was used for the US-guided procedure, and green dye was used for the blind procedure. Two physicians uninvolved with the injection procedures and who were blinded to the method of injection dissected the cadavers to identify whether the dye was accurately injected into each target site. RESULTS: The accuracies of the blind and US-guided injections into the parotid gland were 79.17% and 95.83%, respectively. In the submandibular gland, the accuracies of the blind and US-guided injections were 50.00% and 91.67%, respectively. The difference in accuracy between the two procedures was statistically significant only in the submandibular gland (p=0.025). There were no significant differences in the accuracy of US-guided and non-US-guided injections between the two physicians for the two sites in the parotid gland (p=0.278 and p=0.146, respectively). CONCLUSION: US-guided BTX injection into the submandibular gland offers significantly greater accuracy over blind injection. For the treatment of drooling by injecting BTX into the submandibular gland, clinicians should consider using US guidance for improved accuracy.

Ultrasound Dimensions of the Rotator Cuff and Other Associated Structures in Korean Healthy Adults.

In evaluating patients complaining of shoulder pain, ultrasonography is an emerging imaging tool due to convenience, low cost, high sensitivity and specificity. However, normative values of ultrasound dimensions of the shoulder to be compared with pathologic findings in Korean adults are not provided yet. We evaluated the ultrasound dimensions of the rotator cuff, long head of biceps tendon, deltoid muscle and acromioclavicular joint in Korean healthy adults. Shoulder ultrasonography was performed on 200 shoulders from 100 healthy adults. The dimensions of the thickness of rotator cuff (supraspinatus, infraspinatus, subscapularis tendon), deltoid muscle, long head of biceps tendon, subacromial subdeltoid bursa, and acromioclavicular joint interval were measured in a standardized manner. Differences in measurements among sex, age, and dominant arms were compared. The thickness of rotator cuff tendons (supraspinatus, infraspinatus, subscapularis) and deltoid muscle were significantly different between men and women. The thickness of subacromial subdeltoid bursa was significantly different between men and women for non-dominant side. In rotator cuff tendon measurements, the differences between dominant and non-dominant shoulders were not significant, which means the asymptomatic contralateral shoulder can be used to estimate the normal reference values. When stratified by age divided by 10 years, the measurements of supraspinatus, subscapularis and deltoid thickness showed tendency of increase with the age. The acromioclavicular joint interval, on the other hand, revealed decreasing tendency. This report suggests normative values of ultrasound dimensions of healthy Korean population with varying age, and can be useful as reference values in evaluating shoulder pathology, especially in rotator cuff tendon pathology.

Botulinum toxin type A for neuropathic pain in patients with spinal cord injury.

OBJECTIVE: To evaluate the analgesic effect of botulinum toxin type A (BTX-A) on patients with spinal cord injury-associated neuropathic pain. METHODS: The effect of BTX-A on 40 patients with spinal cord injury-associated neuropathic pain was investigated using a randomized, double-blind, placebo-controlled design. A 1-time subcutaneous BTX-A (200U) injection was administered to the painful area. Visual analogue scale (VAS) scores (0-100mm), the Korean version of the short-form McGill Pain Questionnaire, and the World Health Organization WHOQOL-BREF quality of life assessment were evaluated prior to treatment and at 4 and 8 weeks after the injection. RESULTS: At 4 and 8 weeks after injection, the VAS score for pain was significantly reduced by 18.6 ± 16.8 and 21.3 ± 26.8, respectively, in the BTX-A group, whereas it was reduced by 2.6 ± 14.6 and 0.3 ± 19.5, respectively, in the placebo group. The pain relief was associated with preservation of motor or sensory function below the neurological level of injury. Among the responders in the BTX-A group, 55% and 45% reported pain relief of 20% or greater at 4 and 8 weeks, respectively, after the injection, whereas only 15% and 10% of the responders in the placebo group reported a similar level of pain relief. Improvements in the score for the physical health domain of the WHOQOL-BREF in the BTX-A group showed a marginal trend toward significance (p = 0.0521) at 4 weeks after the injection. INTERPRETATION: These results indicate that BTX-A may reduce intractable chronic neuropathic pain in patients with spinal cord injury.

Efficacy and Safety of a New Botulinum Toxin Type A Free of Complexing Proteins.

MT10107 is botulinum neurotoxin type A derived drug which utilizes the 150 kDa portion without complexing proteins and human serum albumin contents. To evaluate the efficacy and the safety of MT10107, it was compared with onabotulinumtoxinA in this double-blind, randomized controlled trial. Twenty-five healthy males received a randomly selected dose of MT10107 into the extensor digitorum brevis (EDB) muscle of one foot, and an equivalent dose of onabotulinumtoxinA (BOTOX) was injected into the contralateral EDB muscle. While efficacy of the administered substance was determined by measuring paretic effects on the EDB, the local spread of toxin effects was evaluated by the paretic effects on the nearby abductor hallucis (AH) and abductor digiti quinti (ADQ) muscles. Paretic effects were defined as the percentage of reduction of the compound muscle action potential (CMAP) amplitudes, measured at 14, 30, 90 days after the injection, compared to the baseline value. Intergroup (MT10107 and onabotulinumtoxinA) differences were not significant in the percentage reduction of the amplitudes in the EDB muscles. In this study, there was no significant difference in efficacy and safety between the two test drugs. MT10107 may be effective and safe as much as onabotulinumtoxinA to produce the desired paretic effect.

Botulinum Toxin for Neuropathic Pain: A Review of the Literature.

Botulinum neurotoxin (BoNT), derived from Clostridium botulinum, has been used therapeutically for focal dystonia, spasticity, and chronic migraine. Its spectrum as a potential treatment for neuropathic pain has grown. Recent opinions on the mechanism behind the antinociceptive effects of BoNT suggest that it inhibits the release of peripheral neurotransmitters and inflammatory mediators from sensory nerves. There is some evidence showing the axonal transport of BoNT, but it remains controversial. The aim of this review is to summarize the experimental and clinical evidence of the antinociceptive effects, mechanisms, and therapeutic applications of BoNT for neuropathic pain conditions, including postherpetic neuralgia, complex regional pain syndrome, and trigeminal neuralgia. The PubMed and OvidSP databases were searched from 1966 to May 2015. We assessed levels of evidence according to the American Academy of Neurology guidelines. Recent studies have suggested that BoNT injection is an effective treatment for postherpetic neuralgia and is likely efficient for trigeminal neuralgia and post-traumatic neuralgia. BoNT could also be effective as a treatment for diabetic neuropathy. It has not been proven to be an effective treatment for occipital neuralgia or complex regional pain syndrome.

Determination of injection site in flexor digitorum longus for effective and safe botulinum toxin injection.

OBJECTIVE: To determine the optimal injection site in the flexor digitorum longus (FDL) muscle for effective botulinum toxin injection. METHODS: Fourteen specimens from eight adult Korean cadavers were used in this study. The most proximal medial point of the tibia plateau was defined as the proximal reference point; the most distal tip of the medial malleolus was defined as the distal reference point. The distance of a line connecting the proximal and distal reference points was defined as the reference length. The X-coordinate was the distance from the proximal reference point to the intramuscular motor endpoint (IME), or motor entry point (MEP) on the reference line, and the Y-coordinate was the distance from the nearest point from MEP on the medial border of the tibia to the MEP. IME and MEP distances from the proximal reference point were evaluated using the raw value and the X-coordinate to reference length ratio was determined as a percentage. RESULTS: The majority of IMEs were located within 30%-60% of the reference length from the proximal reference point. The majority of the MEPs were located within 40%-60% of the reference length from the proximal reference point. CONCLUSION: We recommend the anatomical site for a botulinum toxin injection in the FDL to be within a region 30%-60% of the reference length from the proximal reference point.

Anatomical localization of the motor entry point in the thyroarytenoid muscle.

INTRODUCTION: The aim of this study was to localize the motor entry point (MEP) of the thyroarytenoid muscle. METHODS: Eight cadaver larynges were dissected. A virtual plane was used to represent the MEP in a coordinate (X/Y/Z) system. The inferior border of the thyroid cartilage was linked to the center of the anterior arc of the cricoid cartilage (the Y-axis). The X-axis was set perpendicular to the Y-axis; the Z-axis passed through the posterior border of the thyroid lamina from the height of the insertion point. RESULTS: The mean X, Y, and Z coordinates were 6.2 mm, 9.1 mm, and 11.0 mm, respectively. The calculated angles of the lateral and superior deflections were 29.4° and 35.8°, respectively. The calculated insertion depth, that is, the distance from the insertion point to the MEP, was 15.6 mm. CONCLUSIONS: These results may help to improve the accuracy of needle insertion during diagnostic laryngeal electromyography or laryngeal electromyography-guided injections.

Inexplicable Abdominal Pain due to Thoracic Spinal Cord Tumor.

Chronic, refractory abdominal pain without a metabolic or structural gastroenterological etiology can be challenging for diagnosis and management. Even though it is rare, it has been reported that such a recurrent abdominal pain associated with radicular pattern can be derived from structural neurologic lesion like spinal cord tumor. We experienced an unusual case of chronic recurrent abdominal pain that lasted for two years without definite neurologic deficits in a patient, who has been harboring thoracic spinal cord tumor. During an extensive gastroenterological workup for the abdominal pain, the spinal cord tumor had been found and was resected through surgery. Since then, the inexplicable pain sustained over a long period of time eventually resolved. This case highlights the importance of taking into consideration the possibility of spinal cord tumor in differential diagnosis when a patient complains of chronic and recurrent abdominal pain without other medical abnormalities.

Anatomic localization of motor points of wrist flexors.

OBJECTIVE: The aim of this study was to determine the location of the motor points and the intramuscular branches of the wrist flexors in relation to bony landmarks. DESIGN: Sixteen limbs from eight adult cadavers were anatomically dissected. The motor branch points of the flexor carpi radialis and flexor carpi ulnaris muscles and the proximal limit points and the distal limit points in relation to a reference line connecting the medial epicondyle and the pisiform bone or one connecting the medial epicondyle and the base of the second metarcarpal bone were identified. RESULTS: For the flexor carpi radialis muscles, the motor branch points were located at a distance of 27% ± 6% of the reference line, whereas the proximal limit points and the distal limit points were located at a distance of 21% ± 5% and 37% ± 8% of the reference line. For the flexor carpi ulnaris muscles, the corresponding data were 32% ± 8%, 23% ± 6%, and 43% ± 9%. CONCLUSIONS: The results may assist in enhancing accuracy when localizing points for neuromuscular blockade of the wrist flexors. The optimal area for flexor carpi radialis muscle injection is at a quarter point and that for flexor carpi ulnaris muscle injection is at one-third point along each reference line from the medial epicondyle.

Intractable abdominal pain in a patient with spinal cord injury: a case report.

Patients with spinal cord injury (SCI) may experience several types of chronic pains. Abdominal pain in patients with SCI has gained limited attention and little is yet known about its characteristics and mechanisms. It often has been regarded as visceral pain associated with constipation and distention. Neuropathic pains localized in the abdomen have rarely been reported. We experience a case of intractable abdominal pain in a patient with SCI, neither of visceral pathology nor of musculoskeletal origin. The nature of pain fulfilled the diagnostic criteria for neuropathic pains. The pain was therefore regarded as neuropathic and managed accordingly. The first- and second-line oral drugs available were being performed, unfortunately, adequate pain control was not achieved. We tried an intrathecal lidocaine injection as another treatment option, and the injection had considerable effects.

Characteristics of dysphagia in children with cerebral palsy, related to gross motor function.

OBJECTIVE: The aim of this study was to report the characteristics of dysphagia in children with cerebral palsy (CP), related to gross motor function. DESIGN: Videofluoroscopic swallow study was performed in 29 children with CP, according to the manual of Logemann. Five questions about oromotor dysfunction were answered. Gross motor function level was classified by the Gross Motor Function Classification System Expanded and Revised. RESULTS: The results of the videofluoroscopic swallowing studies showed that reduced lip closure, inadequate bolus formation, residue in the oral cavity, delayed triggering of pharyngeal swallow, reduced larynx elevation, coating on the pharyngeal wall, delayed pharyngeal transit time, multiple swallow, and aspiration were significantly more common in the severe group (Gross Motor Function Classification System Expanded and Revised IV or V). As for aspiration, 50% of the children with severe CP had problems, but only 14.3% of them with moderate (Gross Motor Function Classification System Expanded and Revised III) CP and none of them with mild CP had abnormalities. In addition, five of the seven aspiration cases occurred silently. CONCLUSIONS: This study shows that dysphagia is closely related to gross motor function in children with CP. Silent aspiration was observed in the moderate to severe CP groups. Aspiration is an important cause of medical problems such as acute and chronic lung disease, and associated respiratory complications contribute significantly in increasing morbidity and mortality in these patient groups. Therefore, the authors suggest that early dysphagia evaluation including videofluoroscopic swallow study is necessary in managing feeding problems and may prevent chronic aspiration, malnutrition, and infections.

Comparative study of biological activity of four botulinum toxin type A preparations in mice.

BACKGROUND: Units of available botulinum toxin preparations are not interchangeable, and the dose-conversion ratios between such preparations remain controversial. OBJECTIVE: To compare the efficacy and safety of four botulinum toxin type A preparations. MATERIALS AND METHODS: Murine gastrocnemius compound muscle action potentials (CMAPs) were recorded before and after injecting the four botulinum toxin preparations (onabotulinumtoxinA, abobotulinumtoxinA, new botulinum toxin, and incobotulinumtoxinA). RESULTS: In all preparations, CMAP amplitudes decreased until 4 days after receiving the injection and then gradually recovered. On postinjection day 84, the amplitudes returned to baseline in all groups except the high-dose groups. CMAP amplitude in the contralateral limb also decreased up to postinjection days 4 to 7 and then gradually returned to baseline by postinjection day 28. CONCLUSION: The dose-conversion ratio between onabotulinumtoxinA and abobotulinumtoxinA was determined to be 1:2.6; previous reports of 1:3 were considered too high. A dose-conversion ratio between onabotulinumtoxinA and new botulinum toxin of 1:1 was deemed appropriate. OnabotulinumtoxinA and incobotulinumtoxinA demonstrated a dose-conversion ratio of 1:1.07. The efficacy of incobotulinumtoxinA was slightly lower than that of onabotulinumtoxinA. These dose-conversion ratios are applicable solely from an efficacy standpoint and not for safety. This study was conducted in mice, so it may not translate perfectly to human applications.

Management of severe bilateral ptosis in a patient with midbrain infarction: a case report.

Ptosis could be caused by oculomotor nerve palsy in the midbrain infarction. Bilateral ptosis has been reported in several reports, which focused on clinical characteristics of midbrain infarction. Little research attention has been paid to the treatment of patients with bilateral ptosis in midbrain infarction. We experienced a case of severe bilateral ptosis occurring after midbrain infarction. The patient could not open her eyes, perform basic activities or achieve effective rehabilitation. Neurogenic ptosis can improved after the underlying cause is treated. However, in this case, bilateral ptosis was not improved after conservative care for 6 months and the patient remained limited in activities of daily living and mobility. Surgical correction of bilateral ptosis was done by the resection of both Muller's muscles. After surgical correction, the bilateral ptosis was much improved and the effect persisted for at least 6 months.

Ischemic stroke in rats enhances bone resorption in vitro.

We hypothesized that the formation and differentialtion of osteoclasts are accelerated and the potential of bone resorption is increased in the hemiplegic bone marrow in the early stage of stroke. We randomly divided white female Sprague-Dawley (SD) rats (n = 30) into two groups, stroke (n = 15) and sham group (n = 15). On the 7th day after stroke, after cutting away the epiphyses of the femurs and tibias, diaphyseal channels were flushed using α-minimum essential medium (α-MEM) and bone marrow cells were collected. Bone marrow stem cells, which were extracted from the femur and tibia, were cultured on the 7th day after middle cerebral artery occlusion. We then estimated the ratio of non-adherent cells to total bone marrow cells that included osteoclast precursor cells. After culturing these cells separately, cells that tested positive on the tartrate resistant acid phosphatase (TRAP) were counted and bone resorption was evaluated by using the OAAS™ plate. In comparison to the control group, the stroke group showed a higher increase of non-adherent cells in the hemiplegic side bone marrow. In addition, after the primary culture, the stroke group showed an increased number of TRAP positive cells and a higher degree of bone resorption estimated by OAAS™ plate. As a result, osteoclastogenesis and osteoclast differentiation are accelerated and the potential of bone resorption is increased in the hemiplegic bone marrow and these changes are detected as early as within the first week after middle cerebral artery occlusion in SD rats.

A nasogastric tube inserted into the gastrocutaneous fistula.

We reported a case in which a nasogastric tube was inserted into the gastrocutaneous fistula, diagnosed by abdominal computed tomography. A 78-year-old man with a history of recurrent cerebral hemorrhage had a percutaneous endoscopic gastrostomy tube due to dysphagia for 2 years. However, soft tissue infection at the gastrostomy site caused the removal of the tube. Immediately, antibiotic agents were infused. For appropriate hydration and medication, a nasogastric tube was inserted. However, there was no significant improvement of the soft tissue infection. Moreover, the amount of bloody exudate increased. Abdominal computed tomography revealed the nasogastric tube placed under the patient's skin via gastrocutaneous fistula. The nasogastric tube was removed, and an antibiotic agents were maintained. After 3 weeks, the signs of infection fully improved, and percutaneous endoscopic gastrostomy was performed again. This case shows necessities of an appropriate interval between removal of the gastrostomy tube and insertion of a nasogastric tube, and suspicion of existence of gastrocutaneous fistula.

The functional effect of epigallocatechin gallate on ischemic stroke in rats.

We evaluated the efficacy of epigallocatechin gallate (EGCG) for improving function in rats with transient middle cerebral artery occlusion (MCAO). Three procedures underwent for each groups; MCAO and EGCG treatment, MCAO without treatment (MCAO control), and sham operation. Function was evaluated on days 1, 5, 10, and 14 after ischemia, using a modified sticky-tape test and the percentage weight borne on the paretic leg. Infarct volume did not differ between the EGCG-treated and MCAO control groups. Compared with the MCAO control group, the EGCG-treated group showed improved forelimb function and had normal function by day 10 (P<0.05). The improvements persisted until day 14 postischemia. In contrast, hind limb function did not differ between the EGCG-treated and MCAO control groups. Thus, EGCG improved certain aspects of function of forelimb until day 14 after MCAO in rats.