Objective:

The aim of this study was to evaluate the relevance of contrast-enhanced ultrasound (CEUS) for evaluating MTrPs vascularity and its potential added value for clinical application.

Background: Muscle trigger points (MTrPs) are a major cause of pain syndromes, and dry needling under ultrasound (US) guidance (DN-US) is a proven and effective treatment for myofascial pain [1] and spasticity [2]. Grey scale ultrasound [3] and sonoelastography [4] provide valuable data for MTrPs identification. MTrPs are also known to be hypovascular [5].

Method: Twelve consecutive patients with low back pain due to MTrPs were included. All patients underwent general exams, precise physical tests, and functional neuromuscular US using 4-8 MHz/5-16 MHz. All patients had MTrPs according to multiparameter US of Doppler, noninvasive flow evaluation, M-mode and SWE and received DN-US protocol according to the approach by R. Bubnov [1]. In two patients who presented highly specific MTrP characteristics, CEUS (SonoVue, Bracco Imaging) was performed. The control group included ten patients without low back pain who had undergone CEUS for other reasons and monitored similar areas during the exam. Careful comparisons were made with contralateral sides and precise focus on the area with specific MTrPs characteristics. Very few needlings (1 needle to the area) were done to avoid local reactions. All MTrPs were confirmed due to LTR, referred pain pattern during needling, and pain relief effect.

Results: Hypovascular areas correlating with Doppler and sensitive vascular imaging (B-flow) were found during CEUS. CEUS demonstrated decreasing vascularization on arterial and venous phases in MTrPs compared to similar areas. All suspected areas were carefully assessed, and contralateral areas were compared during the time the area was observed to increase the specificity of MTrPs of the current area. After DN, pain relief and muscle structure recovery were similar in both groups, vascularization appeared in the targeted area during the procedure.

Conclusion: CEUS is helpful to depict vessels in muscle, and MTrPs are hypovascular according to CEUS. CEUS combined with traditional approaches complies with other US signs of MTrPs. However, due to the complexity of procedure and limited added diagnostic value, CEUS can not be recommended for routine US-DN procedures. Instead, it can be a supporting modality in cases of trauma and tissue damage.

References: 1. Bubnov RV. Evidence-based pain management: is the concept of integrative medicine applicable? EPMA J 2012, 3(1):13. https://doi.org/10.1186/1878-5085-3-13
2. Bubnov RV. Ultrasonography for local muscle spasticity management. Mov Disord 2012, 27(Suppl 1):336.
3. Bubnov R., Spivak M.. Fractal analysis of muscle ultrasound imaging to evaluate muscle health and spasticity. Mov Disord. 2020; 35 (suppl 1): S58.
4. Bubnov R., Kalika L. Shear wave sonoelastography is effective in detecting myofascial trigger points and spasticity. Mov Disord. 2020; 35 (suppl 1): S588.
5. Bubnov R, Golubnitschaja O. Myofascial trigger points are the underevaluated hypoxic nisches altering posture and phenotype. Ann Rheum Dis. 2020;79:1777–1777. https://doi.org/10.1136/annrheumdis-2020-eular.1962.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/the-use-of-contrast-enhanced-ultrasonography-of-muscle-spasticity-and-myofascial-trigger-points/