Combining Ultrasonography and Electromyography for Botulinum Chemodenervation Treatment of Thoracic Outlet Syndrome: Comparison with Fluoroscopy and Electromyography Guidance

Abstract

Background: Botulinum chemodenervation has been increasingly used for treating conditions characterized by muscular pain and dystonia. Complication rates commonly exceed 10 percent in published accounts due to an inadvertent spread of toxin. Various techniques of precision targeting have been described to minimize undesirable toxin effects. The present study reports on a clinical experience combining ultrasonography and electromyography in order to demonstrate how favorably this approach compares to previously described techniques in terms of minimizing complications while maintaining efficacy. Design: Retrospective case series Methods: The present study is a retrospective clinical analysis of patients treated with botulinum toxin using 2 different combined targeting techniques; one using ultrasonography and electromyography and the other using fluoroscopy and electromyography. Results: Combined ultrasonography and electromyography was used in 77 of 245 procedures; in 168 procedures, fluoroscopy and electromyography was used. There were no complications with ultrasonography guided procedures; the complication rate for combined fluoroscopy and electromyography was 1.8 percent (3/168; Fisher exact p = 0.3206). For combined ultrasonography and electromyography, after 70 out of 77 procedures (91%) there was a good outcome compared to 136 out of 168 (81%) after procedures utilizing a combination of fluoroscopy and electromyography (Fisher exact p= 0.331). Conclusions: There was no significant difference in complication rate or successful outcomes comparing the 2 forms of imaging guidance when targeting muscles for botulinum injection. Since outcomes are comparable, other factors such as cost and radiation exposure may be considered in choosing which imaging modality to use. Key words: thoracic outlet syndrome, brachial plexus, botulinum toxin, ultrasound