Original papers

Medical Ultrasonography
2010, Vol. 12, no. 4, 306-310

Sonoelastography contribution in cerebral palsy spasticity treatment

assessment, preliminary report: A systematic review of the literature
apropos of seven patients
Dan Vasilescu1, Dana Vasilescu2, Sorin Dudea1, Carolina Botar-Jid1, Silviu Sfrngeu1,
Dan Cosma2
Radiology Department, University of Medicine and Pharmacy Iuliu Haieganu, Cluj-Napoca, Romania
Cluj Rehabilitation Hospital, Department of Pediatric Surgery, University of Medicine and Pharmacy Iuliu
Haieganu, Cluj-Napoca, Romania

1
2

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 important 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 dorete s prezinte experiena colectivului nostru n aplicarea sonoelastografiei pentru evaluarea spasticitii
musculare. Au fost examinati 7 copii cu spasticitate muscular cu diverse localizri: muchiul relaxat are un aspect moale
(verde-galben-rou) pe cnd cel contractat sau degenerat apare dur (albastru). innd cont de constatrile sonoelastografice
s-a stabilit locul de injectare a toxinei botulinice (Dysport 20 U/kg). Rezultatul obinut a fost o injectare precis i implicit
un rezultat terapeutic favorabil. Trebuie inut cont de mai muli factori ce pot influena evoluia cazului: aspectul muchiului,
vrsta pacientului, dozarea i fracionarea toxinei.
Cuvinte cheie: Spasticitate, toxin botulinic, sonoelastografie

Introduction
Botulinum toxin is a neurotoxin produced by
Clostridium botulinum, a gram-positive anaerobic bacReceived 04.09.2010 Accepted 02.10.2010
Med Ultrason
2010, Vol. 12, No 4, 306-310
Address for correspondence: Dan Vasilescu

University of Medicine and

Pharmacy I. Haieganu Cluj-Napoca,

8 V. Babe str., Cluj-Napoca, Romania

Email: vasilescu.dan@umfcluj.ro

terium. Clinical applications are based on its effect on

the neuro-muscular junction, producing neuromuscular
paralysis. The use of botulinum toxin for medical purposes is mentioned in the late 80s. Initial experiments
were conducted on animals and in the late 90s the first
applications in humans were made. Currently known applications are spastic muscle pathology, in dermatology,
in dystonic torticollis, injections in the submandibular
and parotid glands, and even applications in neurogenic
bladder pathology.
Known products approved for clinical use are:
Onabotulinumtoxin A (Botox), Abobotulinumtoxin A

Medical Ultrasonography 2010; 12(4): 306-310

(Dysport), Rimabotulinumtoxin B (Myobloc) [1].

The applications, including the therapy for spastic muscles, implied injecting the toxin in the targeted
muscle groups. Until a few years ago, the injections
were made only by clinical palpation or by using muscle
stimulation or by using electromyography (EMG). In recent years, ultrasound techniques were introduced to help
guide the injection.
In 2005, Chin et al [2] published a study which
showed the accuracy of tracing the target muscle with
no guidance. They performed 1,372 separate injections
for upper and lower limb spasticity in 226 cases of
children with cerebral palsy. The accuracy of manual
needle placement when compared to electrical stimulation was satisfactory only for gastro-soleus (>75%); it
was not satisfactory for hip adductors (67%), medial
hamstrings (46%), tibialis posterior (11%), biceps brachii (62%), and for forearm and hand muscles (13% to
35%).
Due to the need for a higher accuracy in needle placement in all muscles, ultrasonography (US) became the
method most frequently used in guiding the injections.
The average time needed to identify and inject the targeted muscle ranged from 5 s in superficial muscles, such
as the gastrocnemius muscle, to 30 s in deep-seated muscles [3].
The use of muscle stimulation and of EMG may
produce local pain and increase the stress level.
In pediatric patients the use of minimally invasive
techniques is required and sedation and analgesia is
often needed. In these cases EMG potentials recorded
from the targeted muscles are low. Also, due to the
contraction of the neighboring muscle, EMG might not
always identify the right pathological muscle group.
All these reasons recommend the use of ultrasound
techniques [4].
Sonoelastography is an ultrasound technique that allows the assessment of tissue elasticity. Its application in
the musculoskeletal field includes the evaluation of the
muscle contraction status. On sonoelastographic images
a relaxed muscle structure will appear mostly soft (greenyellow-red), while contracted or degenerated muscle fiber will appear hard (blue) [5,6].
The purpose of this paper is to present our preliminary experience in using ultrasound techniques to guide
the injection of botulinum toxin in the muscles of spastic
children.
Method
In our practice we used 20 U/kg botulinum toxin
(Dysport). Seven patients were included in the study

until now, who were clinically and US pre-injection

evaluated and thereafter on various time intervals.
Patients were selected from Cluj Rehabilitation
Hospital, Department of Pediatric Surgery after orthopedic and neurological examination, having indication for the use of botulinum toxin in relaxing the
spastic muscles. Injections were administered in the
upper and lower limb. The study was approved by the
local Ethics Committee and all the patients or the patients parents gave the consent to participate to the
study.
The ultrasound examination was performed in Cluj
County Emergency Hospital, in Radiology Department, using a Hitachi Ultrasound EUB 8500 with 6.513 MHz linear transducer. The examination consisted
of two-dimensional comparative study of the muscle
groups indicated by the orthopedist and elastography
was used for an accurate assessment and identification of the contracted muscle groups. The ultrasonographic description of the pathological muscle groups
included muscular fibers ecogenicity, ecogenicity of
the fibroadipose septe and the muscle diameter (the
criteria for atrophy included increased ecogenicity of
the muscles and reduced diameter of the fibers when
compared to the opposite site). Sonolastography had
been applied on muscle groups previously identified by
two-dimensional ultrasound examination. As described
before, relaxed muscle structure would appear mostly
soft (green-yellow-red), while contracted or degenerated muscle fiber would appear hard (blue) on sonoelastographic images [6]. Sonoelastographic images obtained were analysed using a dedicated software with
the purpose of obtaining objective and quantifiable
data, useful in establishing an exact imaging diagnosis
and in monitoring this disease. The decision where to
administer the Dysport was made according to the US
findings.
The distance to the pathologic muscle, perpendicular to the skin was measured using points marked
on the surface of the skin at the end of US examination.
Case 1
Five year old boy with cerebral palsy with spasticity predominantly affecting the lower limb muscles.
Clinical and US assessment was performed in calf
and thigh bilaterally previous injection (fig 1, fig 2).
Evident improvement seen on ultrasound images was
confirmed by the parents and by the clinical examination

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Sonoelastography contribution in cerebral palsy spasticity treatment assessment

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

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
Seven year old boy. Cerebral palsy predominantly affecting the upper limb muscles. Clinical and ultrasound
evaluation was performed on the arm and forearm, bilaterally (fig 3, fig 4). Ultrasound appearance was confirmed also by clinical examination.

Case 7
Ten year old boy with cerebral palsy predominant to
the lower limb muscles. No improvement was obtained
after toxin administration.

Case 3
Seven year old girl. Cerebral palsy with predominant
spasticity of the lower limb muscles. First injection was
administered after clinical palpation of the muscle group
indicated by a previous US exam. The failure in clinical
response imposed a new injection, this time with US control (marking points on the patients skin and indicating
the depth of the pathological muscle) (fig 4, fig 5).
This case is a good example of repeating the toxin
administration if there is no favorable response, before
considering that the case as resistant to the therapy. The
incorrect administration of the toxin could be another
reason for this failure

The use of Botulinum toxin in pediatric patients requires a complex evaluation: orthopedic, neurological
and imaging. One of the reasons of therapeutic failures
may be an incomplete evaluation of the case. This suggests the need of teamwork: neurologist-radiologist-orthopedist-physical therapist and that standardized tests
are needed to monitor the evolution of cases.
The cases presented in this paper show related features regarding the location of muscle groups that were
suitable for the injection of botulinum toxin, including
upper and/or lower limbs. In our opinion an unsatisfactory therapeutic result after Botulinum toxin injection
would be expected if the muscles had structural alterations with the appearance of fibrosis (gray scale US); if
the toxin was administrated in other structures than those
indicated by the ultrasound examination; in cases of patients older than 7 years; if the treatment was not followed by a proper physical therapy;

Case 4-6
These 3 patients (age 3, 4, and 7 years) had limb
palsy. After US guided toxin administration all presented
favorable overall evolution.

Results and Discussion

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Sonoelastography contribution in cerebral palsy spasticity treatment assessment

Improvement of protocols for clinical and ultrasound

examination could lower the rate of treatment failure. It
is also necessary to administer a sufficient dose of toxin
to achieve the expected effect and the injection should be
followed by a proper physiotherapy. Dosage should be individualized to each patient and suitably fractionated for
targeted muscle groups. It should also be considered as an
option to inject the muscle in several different points. We
appreciated that the use of US had an important contribution in the easiness of a precise tracking of the muscle
groups, being the easiest technique in pediatric patients.
Schroeder et al [7] concluded that in most aspects ultrasound is superior to EMG (table I). Sonoelastography

improves the findings of grayscale US in assessing the

degree of muscle contraction, especially in the cases with
less information then the ones offered by EMG.
Superior therapeutic results seem to be obtained by combining two-dimensional ultrasound with sonoelastography
to mark the exact injection site or making the approach ultrasound guided, as it can be seen in the 3-rd presented case.
Larger studies are needed to confirm the substantial
contribution of sonoelastography, but also to discover
new aspects that would improve the therapeutic decision.
For a better evaluation of muscle contraction status we
need more experience with the benefits of sonoelastography in the musculoskeletal pathology.

Table I. Differences between EMG, muscle stimulation and US in guiding the toxine injection [7].
EMG

Muscle stimulation

US

Identification accuracy

Time for identify the muscle group

Availability of technical equipment

Pain and stress caused by the method

Dependency on expert experience

Necessary number of stabs

Depth injection control

Differentiation of adjacent muscle groups (also contracted)

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 sedationanalgesia association

Control of neuromuscular junction proximity

Control of muscular hyperactivity

Control of muscle dimension

Control of muscle fibrosis

Potential for future technology development and research

-: unfavourable; +: advantageous; o: acceptable

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injection of botulinum toxin A: a comparison between manual needle placement and placement guided by electrical
stimulation. Pediatr Orthop 2005;25: 286-291.
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cerebral palsy. Lancet 2004;363: 249 250.
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