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1
Radiology Department, University of Medicine and Pharmacy “Iuliu Haţieganu”, Cluj-Napoca, Romania
2
Cluj Rehabilitation Hospital, Department of Pediatric Surgery, University of Medicine and Pharmacy “Iuliu
Haţieganu”, Cluj-Napoca, Romania
Abstract
This paper aims to present our experience of 7 cases of spastic children, using sonoelastography in assessing the muscle
spasticity: the relaxed muscle structures appear mostly soft (green-yellow-red), while contracted or degenerated muscle fibers
appear hard (blue). Using sonoelastographic findings we established the proper place for injecting the botulinum toxin (20 U/
kg Dysport) into the affected muscle. The result was a precise, guided injection, with positive, therapeutic results. It is impor-
tant consider several factors that can influence the evolution of the case: gray scale ultrasound appearance of the muscle, the
patient age, the dosage and the fractionation of toxin.
Keywords: Spasticity, botulinum toxin, sonoelastography
Rezumat
Lucrarea doreşte să prezinte experienţa colectivului nostru în aplicarea sonoelastografiei pentru evaluarea spasticităţii
musculare. Au fost examinati 7 copii cu spasticitate musculară cu diverse localizări: muşchiul relaxat are un aspect moale
(verde-galben-roşu) pe când cel contractat sau degenerat apare dur (albastru). Ţinând cont de constatările sonoelastografice
s-a stabilit locul de injectare a toxinei botulinice (Dysport 20 U/kg). Rezultatul obţinut a fost o injectare precisă şi implicit
un rezultat terapeutic favorabil. Trebuie ţinut cont de mai mulţi factori ce pot influenţa evoluţia cazului: aspectul muşchiului,
vârsta pacientului, dozarea şi fracţionarea toxinei.
Cuvinte cheie: Spasticitate, toxină botulinică, sonoelastografie
Fig 1. a) Left thigh and b) right thigh before injection (gray scale US and sonoelastography). Hard aspect (contracted) of the
medial gastrocnemius muscle.
Fig 2. a) Left thigh and b) right thigh 6 months after from injection (gray scale US and sonoelastography). Gastrocnemius
muscle looks softer (less contracted).
Fig 3. a) Right pronator teres muscle before injection (gray scale US and sonoelastography) predominantly contracted; b) right
pronator teres muscle 4 weeks after injection. The aspect is softer, less contracted
Fig 4. Right abductor policis muscle a) before injection – contracted aspect of the muscle; b) 4 weeks after injection. The aspect
is softer, less contracted
Medical Ultrasonography 2010; 12(4): 306-310 309
Fig 5. a) Initial contracted aspect of left medial gastrocnemius muscle (gray scale US and sonoelastography); b) unchanged
aspect at 2 weeks after injection based on clinical palpation
Fig 6. The same case as in fig 5. a) US reassessment followed by marking the points for injection; b) US control after 3 weeks.
Improved appearance, the muscle looks softer this time
Case 2 Case 7
Seven year old boy. Cerebral palsy predominantly af- Ten year old boy with cerebral palsy predominant to
fecting the upper limb muscles. Clinical and ultrasound the lower limb muscles. No improvement was obtained
evaluation was performed on the arm and forearm, bi- after toxin administration.
laterally (fig 3, fig 4). Ultrasound appearance was con-
firmed also by clinical examination. Results and Discussion
Table I. Differences between EMG, muscle stimulation and US in guiding the toxine injection [7].
EMG Muscle stimulation US
Identification accuracy o + +
Time for identify the muscle group – o +
Availability of technical equipment o o +
Pain and stress caused by the method – – +
Dependency on expert experience – – o
Necessary number of stabs – – +
Depth injection control o o +
Differentiation of adjacent muscle groups (also contracted) o o +
Differentiation of the muscle from surrounding tissues – – +
Dependence on patient cooperation – + +
The possibility to confirm the correct placement after injection – – +
The possibility of injection documentation – – +
Issues related to sedation–analgesia association – + +
Control of neuro–muscular junction proximity + + –
Control of muscular hyperactivity + o –
Control of muscle dimension o o +
Control of muscle fibrosis o o +
Potential for future technology development and research o – +
-: unfavourable; +: advantageous; o: acceptable
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