Musculoskeletal Ultrasound Guidance

By Dr. Evan Friedman | August 29, 2022
The Myoguide System

We have presented many resources about the Myoguide™ EMG/ESTIM BoNT injection guidance system, related to the value of EMG and Stimulation guidance (ESTIM) techniques, including:

  • The availability of EMG signal display
  • EMG audio and options such as audio mute
  • The application of 1.0mA and 0.1mA stimulation steps for ESTIM location procedures

We’d like to underline the value of these concepts when we consider the benefits of integrating these guidance options when ultrasound (US) guidance is being used

We also addressed combined guidance technique in a recent article we posted.  As we know, ultrasound may be used in conjunction with EMG and ESTIM guidance techniques to improve outcomes.  In retrospect, we might have posted this article before the former!

Please check out our latest Ultrasound Guided Injection billing code page, for your convenience.

Ultrasound-guided injection

Ultrasonography is well established as a reliable and reproducible imaging method that is used to identify the anatomy of the muscle.

Musculoskeletal ultrasound (US) is a non-invasive, accurate imaging modality that can be used to diagnose a variety of musculoskeletal injuries and disorders.

US provides accurate real time anatomical information in both cross-sectional and longitudinal views.  Visualization of the needle electrode is usually available. However, if visualization is poor, tissue distortion, which may be visible on the ultrasound image, can be used.

Ultrasound machines consist of several components:

  • Ultrasound transducer
  • Computer processor
  • Display monitor

Transducers are available in high and low frequencies:

  • The high frequency transducers (used for more superficial structures at a high resolution)
  • The low frequency transducers (used to assess deeper structures)

Transducer formats are available in various formats, including:

  • Linear probes have a flat array and appearance. They have a higher frequency (7-15MHz) and are used to scan small parts and shallow structures near the surface.  This is most suited for injection guidance procedures. Linear probes produce a more square or rectangular image. Used primarily for superficial imaging/ needle guidance.
  • Convex probes (also called curved linear probes) have a curved array that allows for a wider field of view at a lower frequency (2-5 MHz). Convex probes are primarily used for abdominal scans due to their wider depth and deeper penetration.  Facilitates examination of deeper regions, such as the hip.
Ultrasound of the Hip Region (labeled)

The advantages of Ultrasound include:

  • Non-invasive
  • No radiation exposure
  • Portable formats available
  • Relatively inexpensive
  • Safe in patients with pacemaker and metal implants
  • No claustrophobia
  • Higher resolution images of superficial soft tissue anatomy than MRI
  • No known contraindications
  • Real time assessment
  • Dynamic examination
  • Can interact with the patient while imaging
  • Rapid contralateral limb examination for comparison
  • Repeatability to monitor disease progression
  • Guided treatment procedures (injections, aspiration, biopsy)

US-guided injection requires the ability to recognize both the longitudinal, as well as, cross-sectional anatomy.  The needle shaft, and/or needle tip, can usually be visualized before the injectate is injected into the target muscle.  Tissue distortion can be used to home into the needle location.

There are many advantages of the US-guided injection with BoNT-A. This technique allows real-time visualization of the needle into structures including the target muscles and adjunct tissues.

This method not only permits the clinician to more precisely identify the target muscles but also permits the avoidance of needle penetration in some other bodily structures, such as the blood vessels and nerves.

Other potential benefits of this technique are that US-guided technique procedure is relatively more efficient with respect to the time needed to conduct this technique.

The clinician is able to visualize the volume of the injected BoNT-A solution in real time, thereby facilitating relocation of the needle tip to different areas within the same muscle to minimize the spread of BoNT-A into adjacent tissues.   

Negatives include the need for additional help carrying out the injection procedures.   This is certainly a more prevalent issue for clinicians who are new to US-guided injections and cannot manage both the injection and the US device themselves.

It is also very advisable that clinicians seek appropriate training to elevate their education level, and familiarity with both the US device techniques, and US anatomy.  Training is a necessity before administering any US technique.

Ultrasound guidance for interventional procedures can provide a higher level of accuracy, improved treatment success and patient safety, as compared to “landmark techniques” since the clinician can see exactly where the needle is being placed. It is also important to recognize the synergy that comes from using combined guidance techniques.

A variety of educational opportunities are offered to provide flexibility and options to best meet the educational needs of the medical professional.  The up and coming AAPM&R meeting in Baltimore, has programs running from Oct. 10th-21st.  There are many lectures and hands-on training opportunities, including the STEP program.

See you at the Skills Lab: Ultrasound Guided Chemodenervation Procedures for the Upper and Lower Limbs, on Thursday, October 20, 2022, 2:00 PM – 5:00 PM (EST)

Please keep your eyes on these blog posts, as we will have some very interesting ultrasound oriented announcements to make in the future!

References

  1. Baloch, N., Hasan, O. H., Jessar, M. M., Hattori, S., & Yamada, S. (2018). “sports ultrasound”, advantages, indications and limitations in upper and lower limbs musculoskeletal disorders. review article. International Journal of Surgery, 54, 333–340. https://doi.org/10.1016/j.ijsu.2017.11.034
  2. Alter KE, Karp BI. Ultrasound Guidance for Botulinum Neurotoxin Chemodenervation Procedures. Toxins (Basel). 2017 Dec 28;10(1):18. doi: 10.3390/toxins10010018. PMID: 29283397; PMCID: PMC5793105.
  3. Alter K.K., Murphy K.P. Guidance techniques for botulinum toxins and other injections. In: Alexander M.M., Matthews D.J., editors. Pediatric Rehabilitation, Principles and Practice. 5th ed. Demos Medical Publishing; New York, NY, USA: 2015. pp. 153–169. 
  4. Alter K.K., Lin J.L. Ultrasound guidance for nerve and motor point blocks. In: Alter K.K., Hallett M., Karp B., editors. Ultrasound Guided Chemodenervation Procedures: Text and Atlas. Demos Medical Publishing; New York, NY, USA: 2012. pp. 170–184. 
  5. Chan A.K., Finlayson H., Mills P.B. Does the method of botulinum neurotoxin injection for limb spasticity affect outcomes? A systematic review. Clin. Rehabil. 2017;31:713–721. doi: 10.1177/0269215516655589. 
  6. Picelli A., Lobba D., Midiri A., Picelli A., Lobba D., Midiri A., Prandi P., Melotti C., Baldessarelli S., Smania N. Botulinum toxin injection into the forearm muscles for wrist and fingers spastic overactivity in adults with chronic stroke: A randomized controlled trial comparing three injection techniques. Clin. Rehabil. 2014;28:232–242. doi: 10.1177/0269215513497735. 
  7. Grigoriu A.I., Dinomais M., Rémy-Néris O., Brochard S. Impact of injection-guiding techniques on the effectiveness of botulinum toxin for the treatment of focal spasticity and dystonia: A systematic review. Arch. Phys. Med. Rehabil. 2015;96:2067–2078. doi: 10.1016/j.apmr.2015.05.002. 
  8. Bhidayasiri R., Truong D. Expanding use of botulinum toxin. J. Neurol. Sci. 2005;235:1–9. doi: 10.1016/j.jns.2005.04.017.  
  9. Davidson J., Jayaraman S. Guided interventions in musculoskeletal ultrasound: What’s the evidence? Clin. Radiol. 2011;66:140–152. doi: 10.1016/j.crad.2010.09.006. 
  10.  Wu T., Dong Y., Song H., Fu Y., Li J.H. Seminars in Arthritis and Rheumatism. Volume 45. WB Saunders; Philadelphia, PA, USA: 2016. Ultrasound-guided versus landmark in knee Arthrocentesis: A systematic review; pp. 627–632.
  11. Wu T., Song H.H., Dong Y., Li J.H. Seminars in Arthritis and Rheumatism. Volume 45. WB Saunders; Philadelphia, PA, USA: 2015. Ultrasound-guided versus blind subacromial-subdeltoid bursa injection in adults with shoulder pain: A systematic review and meta-analysis; pp. 374–378.
  12. Strakowski J.A. Ultrasound Evaluation of Focal Neuropathies: Correlation with Electrodiagnosis. Demos Medical Publishing; New York, NY, USA: 2014. Ultrasound evaluation of peripheral nerves; pp. 65–94.
  13. Comella CL, Buchman AS, Tanner CM, Brown-Toms NC, Goetz CG. Botulinum toxin injection for spasmodic torticollis: increased magnitude of benefit with electromyographic assistance. Neurology. 1992 Apr;42(4):878-82. doi: 10.1212/wnl.42.4.878. PMID: 1565246.
  14. Speelman JD, Brans JW. Cervical dystonia and botulinum treatment: is electromyographic guidance necessary? Mov Disord. 1995 Nov;10(6):802. doi: 10.1002/mds.870100619. PMID: 8750005.
  15. Schnitzler A, Roche N, Denormandie P, Lautridou C, Parratte B, Genet F. Manual needle placement: accuracy of botulinum toxin A injections. Muscle Nerve. 2012 Oct;46(4):531-4. doi: 10.1002/mus.23410. PMID: 22987693.