Ultrasound-Guided Chemodenervation Procedures

15. COMPARING GUIDANCE TECHNIQUES FOR CHEMODENERVATION PROCEDURES
141
manual needle placement by anatomic landmarks and palpation was checked by US.
The medial gastrocnemius was correctly targeted 92% of the time. However, needle
placement in the lateral gastrocnemius was unacceptably low at only 64%. US imaging
of the lateral gastrocnemius reveals that it is much thinner than the medial gastrocne-
mius in nondisabled subjects and even more so in impaired subjects who may have
(a)
(b)
Figure 15.2 (a) Patient with upper motor neuron syndromes, cocontraction (b) upper motor neuron
syndrome, cocontraction and sialorrhea.
Figure 15.3 Acquired hand deformity,
upper motor neuron syndrome.

ULTRASOUND-GUIDED CHEMODENERVATION PROCEDURES
142
disuse atrophy. This fact cannot be appreciated by clinicians using AGP to place a nee-
dle in a muscle for chemodenervation procedures.
Py et al. conducted a prospective study in 2009 to evaluate needle placement by
manual techniques or US guidance (37). They evaluated the effect of age, dose, dilu-
tion, injection site, and guidance technique on overall clinical effectiveness. Included
were 54 children greater than one year of age receiving injections in multiple lower
extremity muscles (gastrocnemius, soleus, hamstrings, adductors). The injections
were performed with US guidance in 56% of patients. Clinical effectiveness was
51% overall, 45% with anatomic guidance and increased to 54% in children receiv-
ing injections guided by US guidance. The authors opined that since the injector had
extensive experience with injection therapy and US guidance, the observed differ-
ences between US and anatomic guidance groups would likely be larger for inexperi-
enced injectors. Effi cacy was reported to be observed highest in patients < 6 years of
age, at doses > 0.8 Units/Kg/muscle (onabotulinumtoxinA) and when the muscles
injected were the hamstrings or gastrocnemius. The effect of toxin dilution was not
signifi cant. The authors concluded US was superior to anatomic guidance for effi cacy
and provided an additional measure of safety when performing chemodenervation
procedures.
Upper Extremity
Because of the complex overlapping arrangement of forearm muscles, muscle localiza-
tion using anatomic landmarks may be diffi cult. This is particularly challenging when
isolation of individual muscle fascicles is required, as is frequently required in patients
with focal dystonia. In an elegant 2010 study, Henzel et al. (18) evaluated 18 patients
with problematic spasticity and compared US localization to surface landmarks using
anatomic guidance methods described for forearm muscles described by Delagi (fl exor
carpi radialis [FCR], Flexor Polices Longus (FPL), Pronator Teres (PT) (14) and Bickerton
(fl exor digitorum superfi cialis [FDS] fascicle isolation) (17). Comparison of US locali-
zation of muscles/fascicles to surface landmarks was described in detail in the study.
Localization methods were compared by Wilcoxon signed rank test and one Sample T
Test. Results indicated signifi cant differences between the optimal site for injection in
several muscles as noted in Table 15.1. The authors concluded that US provided more
accurate targeting for a number of forearm muscles and for isolation of muscle fas-
cicles of the FDS as well as reducing the risk of inadvertent injection into neurovascular
structures.
Cervical Muscles
Recent MEDLINE and Pub Med searches revealed no published references compar-
ing US and anatomic guidance methods for targeting cervical muscles. This may be
related to the fact that most clinicians use EMG guidance for cervical muscles. There
are peer-reviewed articles comparing US guidance and EMG, as well as recent post-
ers comparing the incidence of dysphagia following BoNT injections performed using
EMG versus US guidance to cervical muscles that will be discussed in a subsequent
section (38,39).

15. COMPARING GUIDANCE TECHNIQUES FOR CHEMODENERVATION PROCEDURES
143
Salivary Glands
BoNT injections have been reported to reduce saliva production in patients with sialor-
rhea from a variety of neurological disorders and other conditions (20,40,41). Anatomic
guidance and or US are the only techniques useful for targeting salivary glands. Because
glands contain no muscle content, EMG is not useful when performing chemodenerva-
tion procedures involving salivary glands. Although AGP techniques are described (42)
and have been used in a number of studies, palpation is of limited use when attempting
to locate the parotid or submandibular glands. The vast majority of studies incorporate
US guidance to target the salivary glands (43–48). In 2003, Dobu et al. compared US
guided versus blind injection of the parotid glands (49). The US-guided group had a
signifi cantly greater reduction in saliva production and quantitative saliva assessment
at each follow up visit. Patients who were injected using blind guidance did not have a
statistically signifi cant reduction in saliva using quantitative measures.
US VERSUS EMG
Because many injectors are trained to perform diagnostic EMG during residency or fellow-
ship, EMG is the most commonly used guidance technique for BoNT injections (consider-
ing that AGP are used for all injections). Either a standard EMG machine or audible EMG
amplifi er may be used for EMG guidance (Figures 15.4–15.6). A specialized injecting/
hypodermic needle electrode is required for EMG guidance. These monopolar electrodes
require placement of ground and reference electrodes. The reference should be placed close
to the needle insertion site for differential amplifi cation of the signal. When using EMG
guidance alone, the clinician selects a site for needle insertion using AGP techniques and
or reference guides and listens for activity in the muscle. The needle is blindly advanced
to the target muscle and the position is adjusted until high frequency, crisp motor unit
activity is observed or heard. In “passive EMG recording” EMG guidance provides infor-
mation about activity in the targeted muscles. This is particularly useful in patients who
have baseline muscle overactivity at rest such as those with cervical dystonia. The level of
motor unit activity in the muscle may guide muscle selection and dosing in these patients.
EMG guidance can also be “active,” where the patient is asked to activate a muscle with
the needle in place to confi rm the location in the correct muscle or muscle fascicle. This
technique is frequently used in patients with focal dystonias such as writer’s cramp or
musician’s dystonia (3). In patients with UMN syndromes, attempting to target a specifi c
Table 15.1 Differences between US and surface localization sites in the forearm using proximo-distal
and lateral coordinates
Proximal-Distal Site
Lateral Distance from Reference Line
FPL p 0.042a
FDS-3 p 0.011a
PT p 0.003a
FCR p 0.023a
FCR p 0.066 b
FDS-2 p 0.052b
FDS-4 p 0.088b
a Statically signifi cant.
b Trend toward signifi cance.

ULTRASOUND-GUIDED CHEMODENERVATION PROCEDURES
144
Figure 15.4 EMG machine.
Figure 15.5 EMG signal amplifi er.

15. COMPARING GUIDANCE TECHNIQUES FOR CHEMODENERVATION PROCEDURES
145
muscle by listening for EMG activity may be diffi cult or impossible (2,50). This is due to
multiple factors including cocontraction of agonist and antagonist muscles, generalized
increase in muscle activity in a specifi c region (i.e., all forearm fl exors may show increased
EMG signal), impaired ability to “relax,” lack of motor control and anatomic rearrange-
ments from spasticity/dystonia. All of these factors obscure isolation of individual muscles
using EMG. For example, when targeting the FCR, EMG activity on needle insertion only
confi rms that the needle is in an active muscle, not that the needle is in the FCR. These fac-
tors along with the inability to assess the depth of the target and location of neurovascular
structures are distinct disadvantages when using EMG, alone, as a guidance technique for
chemodenervation.
In addition to the above limitations, another limitation of using EMG guidance for
chemodenervation is the questioned accuracy of needle placement during blind nee-
dle insertion. Numerous studies question the accuracy of blind EMG needle insertion
in muscles of the upper and lower extremities, even when targeting muscles which are
generally considered facile (2,3,21,22,23).
EMG VERSUS US GUIDANCE: WHAT’S THE EVIDENCE?
In 2011, Boon et al. (23) reported the accuracy of fi ne wire placement using EMG and
US in 14 lower limb muscles using fresh frozen cadaver specimens. Placement was
performed by two clinicians, one with extensive EMG experience, the other a resident
with 6 months EMG training. The placement was considered “accurate” if the wire was
within, or just deep (<5 mm) to the target, and inaccurate if outside this zone. The prox-
imity of the wire to neurovascular structures was also recorded. Overall, accuracy of
blind placement was only 39%, whereas accuracy of US-guided wire placement was
96%. In blind insertions, accuracy ranged 0% in the extensor hallices and rectus femoris
to 100% in the tibialis anterior. Accuracy for US-guided insertions was 100% in 13 of 14
muscles with lower accuracy in the semitendinosis (50%). Of note, is that overall, there
was no statistical difference in the accuracy of blind wire placement by the more experi-
enced clinician. This contradicts a long held belief by experienced electromyographers
that they can accurately target a muscle using blind technique.
Chen et al. (50) in a retrospective study compared the effi cacy of US versus
cystoscopy:EMG-guided BoNT injections in treating detrussor/external sphincter dys-
function in patients with neurogenic bladder from spinal cord injury. When comparing
treatment with similar doses of BoNT, they found equivalent treatment effi cacy with
either transrectal US guidance or cystoscopic-EMG guidance. Given the lower cost with
US compared to cystoscopy procedures, US guidance could be considered as an alterna-
tive method for these procedures.
COMBINED US:EMG GUIDANCE
In a retrospective study, Jordan et al. (51) compared BoNT injections using US/EMG
versus fl uoroscopic/EMG guidance BoNT injections in patients treated for thoracic
outlet syndrome (TOS). US + EMG was used in 77 of 245 procedures; fl uoroscopy
and EMG was used in 168 of 245 procedures. In the US-guided group, there were no
complications. In the combined fl uoroscopy and EMG group, the complication rate
was 1.8% (3/168; Fisher exact p = 0.3206). A good outcome was reported in 91% of

ULTRASOUND-GUIDED CHEMODENERVATION PROCEDURES
146
patients who received injections using combined US/EMG versus 81% of patients
whose injections were guided using fl uoroscopy/EMG guidance (Fisher exact
p = 0.331). The authors concluded that there was no signifi cant difference in complica-
tion rate or successful outcomes comparing the two forms of imaging guidance in this
study of BoNT injections for TOS. They also concluded that when considering other
factors such as cost and radiation exposure, US may be the preferred guidance for
injection therapy for TOS.
E-STIM FOR CHEMODENERVATION
E-Stim is commonly used to guide a variety of chemodenervation procedures including
BoNT injections, motor point and nerve blocks (1,3,4,52). E-stim can be performed using
the stimulator of a standard EMG machine or by various hand-held portable stimula-
tors (Figures 15.6 and 15.7). E-Stim is required for diagnostic or therapeutic nerve and
motor point blocks. After blind needle insertion the needle is advanced, while stimulat-
ing (starting at 1 to 3 mA). The needle is advanced until low-level stimulation (0.2–0.5
mA) produces a maximal twitch response in the distribution of the target nerve or
within the muscle target of a motor point block (53).
E-Stim, in many circumstances, provides a more direct assessment of needle location
(i.e., twitch response with stimulation) than does recording of passive EMG activity. For
this reason, many clinicians believe E-Stim is superior to passive EMG when performing
BoNT injections (1–3,54). E-Stim, when performed with blind needle insertion suffers
from some of the same limitations listed for EMG including the inability to accurately
assess the depth or location of the target or neurovascular structures to be avoided. In
addition E-Stim is uncomfortable at best and quite painful for many patients. Because of
pain and limited cooperation, E-Stim generally requires sedation in pediatric patients,
increasing the risk of the procedure (53). In addition, E-stim does not ensure that the
injectate stays within targeted muscle fascial borders while this can be assessed during
US guidance.
E-STIM VERSUS US FOR CHEMODENERVATION AND NERVE
BLOCK PROCEDURES
In a prospective study, Kwon et al. (55) compared the effi cacy of BoNT injections
with E-stim versus US guidance in children with CP and spastic equinus gait. In this
study, 32 children were enrolled in separate categories based on their Gross Motor
Function Classifi cation System (GMFCS), then divided into two groups alternately
allocated to US (n = 16) or E-Stim (n = 14) guidance. Equal dose/dilution of BoNT
A was injected into the gastrocnemius at four to six sites. MAS, Modifi ed Tardieu
Scale (MTS), Selective Motor Control (SMC), and Physician’s Rating Scale (PRS) were
measured at baseline, 1 month, and 3 months post treatment. Statistically signifi cant
improvement in the US group was noted in subscales of the PRS (gait pattern and
hindfoot position-maximum foot/fl oor contact during stance). No statistical differ-
ences were noted in MAS, MTS, and SMC. The authors concluded that the visual
feedback provided by US could improve the accuracy of selective neuromuscular
blocking of the gastrocnemius.

15. COMPARING GUIDANCE TECHNIQUES FOR CHEMODENERVATION PROCEDURES
147
COMBINED US AND E-STIM
E-Stim or EMG can be combined with US when necessary to further enhance muscle
target localization if desired (Figure 15.8). Willenborg et al. (56) described a technique
for combined US: Active EMG technique for guiding chemodenervation procedures tar-
geting the psoas muscle. Patients are positioned supine and the bellies of the psoas and
iliacus were isolated using US. The needle was then attached to a nerve stimulator and
stimulation applied confi rming location in the target muscle. They reported signifi cant
improvements in hip extension, abduction and popliteal angle following injection. No
complications were reported using this technique.
Figure 15.6 Combined EMG signal amplifi er/
nerve stimulator.
Figure 15.7 Nerve stimulator.

ULTRASOUND-GUIDED CHEMODENERVATION PROCEDURES
148
US, E-STIM AND NERVE BLOCKS
In addition to its use for chemodenervation procedures, E-Stim is widely used by anes-
thesiologists for regional anesthesia. In the last 10 years the use of US with E-Stim or
US alone to localize nerves for regional nerve blocks has become standard practice. As a
result, there is an extensive literature base comparing US and E-Stim for regional anesthe-
sia procedures. The literature universally supports the advantages of US-guided nerve
blocks over E-Stim or landmark-based guidance techniques. US guidance is reported
to reduce the time of the procedure, the number of needle passes, and to improve the
results of the block. Reduced complication risk is reported in some procedures includ-
ing local anesthetic induced seizures and nerve injuries (57–65). US guidance is increas-
ingly used alone, or more often in combination with E-Stim, for chemodenervation
nerve blocks and provides similar benefi ts when compared to E-Stim guidance alone
(66–68). US-guided chemodenervation procedures for nerve blocks are covered in detail
elsewhere in this text.
US-GUIDED CHEMODENERVATION PROCEDURES
The fi rst reported use of US and BoNT therapy was in 1996 in which US was used to eval-
uate an esophageal injury following BoNT injection with balloon dilation for the treatment
of achalasia (69). In the past decade, numerous articles have been published describing
various US-guidance techniques for BoNT injections and nerve blocks targeting various
structures and body systems including muscles, nerves, salivary gland, bladder, prostate,
GI applications, and others (42–51,70–84). A recent MEDLINE search for the terms “BoNT
injections and US” returned over 120 articles (dating from 1997) and a search for “US and
Nerve blocks” returned over 1400 articles (dating from 1961). As it has when used for
regional anesthesia, US is rapidly gaining widespread acceptance as a more accurate or
perhaps the most accurate method of targeting for chemodenervation procedures.
(a)
(b)
Figures 15.8 (a) Combined US EMG for iliacus (b) combined US guidance and E-Stim or EMG of fore-
arm M muscles.

15. COMPARING GUIDANCE TECHNIQUES FOR CHEMODENERVATION PROCEDURES
149
US provides the advantages of real-time assessment of the location and depth of
target structures, and the best path to the target structure. US also provides a direct
assessment of the position of structures to be avoided including neurovascular struc-
tures, lung, other organs and viscera. Techniques for US-guided BoNT injections of
salivary gland, cervical, oromandibular, upper/lower limb, and trunk muscles have all
been described. US guidance for a variety of muscle overactivity conditions including
UMN syndromes including CP, stroke, and dystonia (focal, segmental, generalized)
have been reported. US guidance for BoNT injections for a variety of other indications
and conditions including TOS, pain conditions, arthritis, vascular impingement, gas-
trointestinal (GI) and genitourinary (GU) indications are also described. The clinical
applications for US-guided BoNT injections and nerve blocks are covered in detail else-
where in this text.
US EVALUATION OF EFFECTS OF CHEMODENERVATION
In 2001, To et al. (85) evaluated masseter muscle appearance and EMG activity pre and
post injection after US-guided BoNT injections. US measurements showed maximum
reduction in masseter size of 30.9% at 3 months post injection indicating that precise
toxin delivery caused anticipated atrophy of the targeted muscle. No change in EMG
was reported although the methodology to compare EMG signals was not described.
US has been reported to improve the effi cacy of toxin injections on gait and range of
motion (ROM) and other functional tasks, see above sections of this chapter describing
US guidance and AGP, EMG, or E-Stim (35).
US GUIDANCE AND REDUCED ADVERSE EVENTS FOLLOWING BONT
INJECTIONS AND CHEMODENERVATION
Adverse events associated with BoNT injections are most often due to direct spread
of the toxin from the target muscle or structure to adjacent muscles/structures or less
often, to distant sites (49,53,84,86–89). Intuitively, it would seem that increasing the
accuracy of BoNT injections and reducing toxin spread when injecting muscles could
reduce the incidence of side effects or adverse events. Data to support this potential
advantage for US-guided injections is limited. However, a recent study examined fi ve
patients with cervical dystonia being treated with BoNT who had recurrent dyspha-
gia after injections. Specifi cally, there were 34 episodes of dysphagia over 98 injec-
tion sessions using EMG guidance for a cumulative dysphagia rate of 34.7%. When
these patients were switched to US guidance using the same injection protocol, 0%
episodes of dysphagia were noted after 27 injection sessions. Measurements of the
sternocleidomastoid muscle (SCM) in the fi ve patients were compared to age and gen-
der matched controls. Data did not show signifi cant differences between groups and
the total muscle thickness measured from skin was only 1.1 cm. The authors stated
that US guidance eliminated recurrent dysphagia after BoNT treatment possibly by
keeping the injectate within the SCM and avoiding direct spread of toxin to deep pha-
ryngeal muscles (38,39).
As noted above the application of US guidance for nerve blocks is standard prac-
tice for regional anesthesia, and is in common use for chemodenervation-related nerve
blocks using phenol or alcohol. There are numerous articles reporting the advantages of

ULTRASOUND-GUIDED CHEMODENERVATION PROCEDURES
150
US-guided nerve blocks over landmark or E-Stim-based techniques, as described above
(57–64). Given that chemodenervation nerve blocks employ similar techniques, the
same advantages and benefi ts are likely to apply to these procedures. As noted above,
US guidance for peripheral nerve blocks has been reported to reduce the incidence of
local anesthetic induced seizures and peripheral nerve injury (61).
SUMMARY
The purpose of this review is to provide updated information about the accuracy of
and inherent advantages/disadvantages of guidance techniques available to clini-
cians during chemodenervation procedures. Given the risks associated with various
chemodenervation procedures, clinicians should choose the most accurate guidance
technique available to them. The vast majority of clinicians would agree that for most
procedures this requires more than just landmark-based localization techniques or
palpation. While EMG and E-Stim each provide more accuracy than palpation alone,
these techniques suffer from limitations. The accuracy of US guidance for a variety
of procedures including neurologic and musculoskeletal applications is well estab-
lished. While additional studies are required to prove that US improves the outcome
and reduces adverse events associated with chemodenervation procedures, it is clear
that US provides clinicians additional information than when using EMG or E-Stim
alone. With the increased portability and decreased cost of US equipment, this tech-
nology has become accessible to physicians of various specialties. These clinicians
are likely to recognize the benefi ts of US and add US as a stand-alone technique or in
combination with EMG and E-Stim to increase the precision and accuracy of chemod-
enervation procedures.
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607–8, 610.

Trunk
Katharine E. Alter and Michael C. Munin
Patients with impairments involving numerous body systems may be referred for, and
benefi t from chemodenervation procedures. Botulinum neurotoxin (BoNT) therapy has
expanded from its initial application for ophthalmologic problems (strabismus and blep-
herospasm) to treating a wide variety of clinical problems including neurological, neuro-
secretory, gastrointestinal, urologic, musculoskeletal, and pain conditions. Ultrasound
(US) has been investigated or is commonly used to guide injections for many, if not
most of these procedures. This chapter covers examples of specifi c clinical applications
of US guidance for BoNT therapy including muscle hypertonia, salivary glands, and
musculoskeletal conditions. Detailed discussion of US-guided BoNT therapy for other
body systems are beyond the scope of this text, but will be mentioned briefl y. US-guided
nerve blocks are covered elsewhere in this text.
PATIENT SELECTION
For patients who have muscle overactivity, neuro-secretory dysfunction, or pain condi-
tions, a detailed history and physical examination are necessary to confi rm the diag-
nosis, review prior treatments, and assess current functional abilities/limitations. This
evaluation will help formulate reasonable treatment goals that can be attained with neu-
rotoxin injections or other chemodenervation procedures. For example, not all patients
presenting with hypertonia from an upper motor neuron (UMN) syndrome have prob-
lematic muscle overactivity that requires injection therapy. A detailed assessment is
required to determine whether treatment of muscle overactivity is indicated. The infor-
mation obtained during patient assessment will help the physician determine if physi-
cal therapy, occupational therapy, speech therapy, oral medications, surgical procedures
and or chemodenervation are warranted (1,2). As the focus of this text is technical, and
specifi c to US guidance for chemodenervation, it is assumed that the patient’s physician
has performed this evaluation and selected chemodenervation as the most appropriate
intervention for an individual patient.
INJECTION TECHNIQUES FOR BOTULINUM TOXIN THERAPY
BoNT injections and nerve block chemodenervation procedures using phenol or ethyl
alcohol require precise localization of the target. As a result, clinicians use a variety of
16
US-Guided Neurotoxin (BoNT) Injections:
Clinical Applications

16. US-GUIDED NEUROTOXIN (BONT) INJECTIONS
155
localization techniques including palpation, electromyography (EMG), electrical stimu-
lation (E-Stim), fl uoroscopy, US, and combinations of these techniques (1–4). The advan-
tages and disadvantages of the various injection guidance techniques are discussed
elsewhere in this text.
The fi rst reported reference to US guidance for nerve blocks was in 1985 to guide
celiac plexus alcohol blocks (5). The initial reported use of US for BoNT injections was
in 1996, following BoNT injections for achalasia (6). Recent MEDLINE and Pub Med
searches for “US-guided nerve blocks” and “US-guided BoNT injections” revealed over
800 articles related to nerve blocks and nearly 50 articles referencing US guidance for
BoNT injections.
MUSCLE HYPERTONIA: UMN SYNDROMES, SPASTICITY,
DYSTONIA AND OTHERS
The reader is referred to illustrations, US images and videos of US-guided techniques
for BoNT injections in the print and DVD Atlas sections of this text.
UPPER LIMB INJECTIONS
Most muscles of the upper limb are easily localized with US using either a longitudinal
or transverse scanning approach. As a rule, the transverse view is superior for distin-
guishing the fascial planes between various muscles such as the biceps/brachialis in the
arm, fl exor forearm, or posterior calf muscles. The fascial planes between muscles may
be less distinct with a longitudinal scan (Figure 16.1a,b). When scanning the forearm,
a transverse scan often provides a better view of the complex, overlapping orientation
of forearm muscles, as well as the location/orientation of neurovascular structures to
be avoided during injection therapy (Figures 16.2a,b). Longitudinal muscle scans may
be superior in some patients, particularly when the goal is to isolate individual muscle
fascicles. Isolation of individual muscle fascicles is often required when treating patients
with focal dystonia. For this technique, the patient is directed to perform active range of
motion (AROM) of individual digits, in series. High frequency US scanning can easily
discriminate between the individual fascicles and the injections can then be directed in
real-time to the desired fascicle. This technique may be more diffi cult in patients with
UMN syndromes due to impaired motor control. In this circumstance, the physician or
an assistant, can perform passive range of motion (PROM) of the digits while observing
the movements observed on the US display screen.
Focal Upper Limb Dystonias
For patients with primary focal or segmental dystonia, virtually any muscle group
may be involved and require injection. A variety of anatomic atlases and techniques

ULTRASOUND-GUIDED CHEMODENERVATION PROCEDURES
156
are described for muscle localization (7–11). B-mode US is an ideal guidance technique
for these injections as it provides a detailed view of the anatomy that is not provided
with any other localization technique. This includes the depth of the target, orientation,
and the location of individual fascicles to be injected. The patient is asked to move each
fi nger, individually, and movement in the muscle fascicles is observed. This localiza-
tion directs the site for injection allowing the clinician to avoid injection of uninvolved
muscle fascicles. The spread of the toxin can be observed during injection to avoid over-
loading a fascicle or spread to adjacent fascicles/muscles. This real-time US technique is
(a)
(b)
Figure 16.1 (a) Transverse scan fl exor muscles, arm (b) longitudinal scan, fl exor arm.
(a)
(b)
Figure 16.2 (a) Transverse view, proximal fl exor forearm (b) Longitudinal view, proximal fl exor
forearm

16. US-GUIDED NEUROTOXIN (BONT) INJECTIONS
157
quick, simple, and provides exquisitely accurate placement of the toxin. In the opinion
of the authors US localization of muscle fascicles is superior to other localization tech-
niques for this indication (7–11).
UMN Syndromes
Although other patterns may be encountered, fl exion-synergy of the arm is common in
patients with spasticity or dystonia from UMN conditions like stroke and cerebral palsy
(Figure 16.3). Muscles commonly targeted for BoNT therapy include proximal muscles
acting on the shoulder and elbow such as the pectoralis, latissimus, teres major, biceps,
and brachialis. In the forearm, common fl exor muscles injected include the brachio-
radialis, pronator teres, fl exor carpi radialis, fl exor digitorum superfi cialis/profundus,
and fl exor pollicis longus. US is particularly useful in patients with limited selective
motor control and synergy patterns where they have diffi culty relaxing muscles since
EMG may show increased activity globally but US can isolate the target muscle directly.
Regardless of whether US is used for these injections, the physician typically requires an
assistant to maintain the patient’s limb in an optimal position for injection therapy and
to prevent involuntary movements.
LOWER LIMB INJECTIONS
Nearly all muscles of the lower limb and hip girdle are readily visualized with US guid-
ance. In obese patients, visualization of the muscles may be compromised by the depth
of the overlying adipose tissue, requiring use of a lower frequency transducer between
4 to 8 Mhz. Despite the reduced resolution of images obtained with lower frequency
transducers, US is the most accurate targeting technique in obese patients. US provides
Figure 16.3 4-year-old with limited
supination due to fl exed, pronated
arm posture.

ULTRASOUND-GUIDED CHEMODENERVATION PROCEDURES
158
accurate assessment of the thickness of the adipose tissue as well as the depth of the
muscles and the fat/muscle interface.
Primary Onset Segmental Or Focal Dystonia
As in the upper limb, lower limb muscle involvement is patient-specifi c and highly
variable. Clinical observation and functional assessment will direct the course of
treatment.
UMN Syndromes
Lower limb muscles most commonly targeted including hip fl exors, adductors, knee
fl exors/extensors, ankle plantar fl exors/inverters, toe fl exors, and the extensor hallicus
longus.
Hip Girdle and Pelvic Muscles
Without the direct visual guidance provided by B-Mode US, injection of deep muscles
of the hip and pelvis is challenging. These muscles are deep and diffi cult to palpate yet
can be seen easily with US while avoiding nearby blood vessels and nerves.
Hip Flexors
There are several approaches described for US-guided injections of hip fl exor muscles.
Iliopsoas, Distal, Anterior Approach
A transverse scan at the distal inguinal crease provides an excellent view of the iliopsoas
muscle and adjacent structures including the sartorius, rectus femoris, pectineus, femo-
ral head, vessels, and nerves (Figure 16.4) (12–15).
Psoas
Several approaches are described including a posterior approach through or lateral
to the paraspinal muscles and an anterior approach through the abdomen (15,16).
In the proximal posterior approach, a localization scan is performed scanning
from L2–4. The psoas is viewed deep to the paraspinal muscles and the needle is
directed through the superficial muscles to the deeper layer of the psoas. Willenborg
describes an anterior-lateral approach at the anterior superior iliac spine, directing
the transducer medial and scanning proximal to distal. The needle is angled at 45°
from the anterior superior iliac spine (ASIS) into the psoas. Care must be used to
avoid bowel and iliac structures (14). An anterior approach, through the abdomen
is described by Brunenghi-Marre et al. This technique has not been used by the
authors and therefore is not discussed further.

16. US-GUIDED NEUROTOXIN (BONT) INJECTIONS
159
Iliacus
The most commonly reported approach is needle insertion, under US guidance, often in
combination with EMG (14). EMG may not be necessary in all patients with a thin body
habitus clinicians with extensive experience with this approach. The iliacus is visual-
ized at its origin on the pelvic side of the ilium. The needle is inserted immediately to
the anterior superior iliac spine and directed into the muscle, away from bowel contents
which will be visualized more medially (Figure 16.5).
Figure 16.4 Transverse view, iliop-
soas, distal at inguinal crease.
Figure 16.5 Iliacus at ASIS.

ULTRASOUND-GUIDED CHEMODENERVATION PROCEDURES
160
Piriformis
Piriformis syndrome is a common cause of low back and buttock pain as well as sciatica.
Injection of BoNT provides relief for many patients who fail to respond to conservative
treatments. US, EMG, and fl uoroscopic guidance have all been described. As previously
mentioned, US has distinct advantages over fl uoroscopy. Sonopalpation can often be
used to locate a trigger point in the most painful area and directs the injection to this
area. US guidance also reduces the risk of inadvertent injection or injury to the sciatic
nerve (Figure 16.6) (17–20).
Posterior Calf
Plantar Flexors and Invertors
The gastrocnemius, soleus, and tibialis posterior are three of the most frequently tar-
geted muscles for spasticity management. Although most clinicians seem confi dent in
targeting the gastrocnemius with manual placement or EMG, evidence would suggest
otherwise. Placement of the needle with manual guidance, checked with US reveals a
failure to target the gastrocnemius in 22% to 63% of injections. US has been shown to
increase the accuracy of needle placement in this muscle (21,22). US provides accurate
assessment of the depth of the relatively thin lateral gastrocnemius and also reveals its
posterior, not lateral location in the calf. Accurately targeting the tibialis posterior, lying
deep to the gastrocnemius and soleus can be challenging even with E-Stim. The tibialis
posterior is often targeted with an anterior approach requiring a precise angle of inser-
tion to reach the target (22,23). US facilitates localization of the tibialis posterior from
either an anterior approach or from the less technically challenging posterior approach.
In the posterior approach, the tibialis posterior is visualized deep to the overlying gas-
trocnemius and soleus muscles. US reveals the close relationship of these muscles in
the posterior calf, the depth of the individual muscles, and the location of the posterior
Figure 16.6 longitudinal view piri-
formis at insertion.

16. US-GUIDED NEUROTOXIN (BONT) INJECTIONS
161
tibial vessels and nerve (Figure 16.7) (3,11,12). Because all three muscles can be viewed
at a single level, multiple muscles can be targeted via a single needle insertion, reduc-
ing the number of needle sticks. When using this technique, the fi rst author recom-
mends injecting the superfi cial muscles fi rst, then proceeding to the deeper layers. With
this technique, the fi rst author has observed reduced movement of the injectate from
the deep to superfi cial layers through the track that is created by needle insertion. The
author postulates that when the superfi cial muscles are injected fi rst, the distension of
the muscle created by the injectate leads to increased pressure in the superfi cial mus-
cle. This creates a pressure gradient that resists fl ow into the superfi cial muscle when
deeper muscles are injected. If the deeper muscles are injected fi rst, these muscles are
under greater pressure than adjacent superfi cial layers favoring fl ow of the injectate
from the deep muscles into the superfi cial muscles.
HEAD AND NECK
As in the limbs, most head and neck structures targeted for neurotoxin therapy are eas-
ily localized using US. This includes the salivary glands, as well as oromandibular and
cervical muscles. Many of the muscles of facial expression are quite thin and superfi cial.
These muscles generally do not require EMG or US guidance and are generally injected
using a subdermal/intramuscular injection using a 30G, 0.5 inch needle.
Salivary Glands
Sialorrhea is a common clinical problem in a variety of neurological disorders includ-
ing cerebral palsy, Parkinson disease, and ALS. Other than anatomical guidance (24)
and palpation, US is useful in accurately localizing the parotid and submandibular
glands, which are commonly targeted for toxin therapy (25–27). Glandular tissue has
Figure 16.7 Transverse view, posterior
calf at distal head of gastrocnemius.

ULTRASOUND-GUIDED CHEMODENERVATION PROCEDURES
162
a uniform grey appearance (Figure 16.8) compared to the striated or “starry night”
appearance of muscle (Figures 16.6 and 16.7). Precise localization of salivary glands is
necessary to reduce the risk of dysphagia. Clinicians should use caution when consid-
ering botulinum toxin therapy in patients with ALS given reports of increased bulbar
weakness (28).
Cervical Muscles
All cervical muscles can be localized with US guidance. US provides useful informa-
tion regarding the location of structures to be avoided when injecting cervical muscles
including large vessels (carotid, jugular), nerves (phrenic, brachial plexus), as well as
the apices/upper lobes of the lungs (Figure 16.9) (29,30). The authors routinely use US
for all injections of scalene muscles when treating patients with cervical dystonia (CD)
or thoracic outlet syndrome (TOS) (31–33). US is particularly helpful when injecting the
neck muscles of patients with CD when muscle atrophy after repeated injections makes
palpation more diffi cult.
PAIN INDICATIONS
The effects of botulinum toxins on reducing pain in a variety of conditions have long
been reported. The antinocioceptive effects of the toxins, at least in part, are due to
the effects on SNARE (Soluble N-ethylmaleimide sensitive fusion attachment protein
receptor) proteins and diminished release of pain neurotransmitters. This mechanism of
action represents a separate pathway from the primary action of BoNT to inhibit acetyl-
choline release in muscle (34,35). In the United States, BoNT therapy for pain indications
is currently “off label,” other than for improving pain associated with migraine head-
ache, CD, overactive bladder, or upper limb spasticity.
Figure
16.8 Parotid
gland
post
injections.

16. US-GUIDED NEUROTOXIN (BONT) INJECTIONS
163
Pain/Headache
As of the date of this publication, onabotulinumtoxinA is the only botulinum toxin
approved in the United States for treatment of migraine headache (36). No references
specifi c to US guidance for BoNT injections and headache were revealed during a lit-
erature search. There are several reported protocols for BoNT injection in migraines
including a “follow the pain” approach and fi xed dose protocols. Muscles typically
injected include the glabella, frontalis, temporalis, suboccipital/posterior cervical
muscles, and trapezius. As previously noted, guidance, including palpation is gener-
ally not required when injecting the muscles of facial expression and other superfi cial
muscles of the face (19,37,38). These muscles are commonly injected in both “follow
the pain” and “fi xed dose” headache protocols. US guidance may be helpful/useful
in localizing posterior cervical muscles and the temporalis muscles when injecting for
headache.
Migraine
OnabotulinumtoxinA is approved for the treatment of chronic migraine with specifi c
qualifi cations on the number of symptomatic days per month. Doses range from 100 to
155 Units of onabotulinumtoxinA (36). Other products are also used, but are not Food
and Drug Administration (FDA) approved for this indication.
Cervical Dystonia
Pain is a common complaint in patients with CD and can be debilitating. Reduced
posturing/pulling pain, and improved quality of life following BoNT therapy are all
reported benefi ts of treatment (19). When selecting muscles for injection therapy, EMG
localization may be useful in determining increased activity in the target muscles. US
Figure 16.9 Anterior, middle scalenes,
brachial plexus transverse view.

ULTRASOUND-GUIDED CHEMODENERVATION PROCEDURES
164
provides the added benefi t of direct visualization of the complex layers of muscles in
the head and neck (Figures 16.8 and 16.10) (30). Following repeated injections, cervical
muscles are often thin and atrophied. In this circumstance, US guidance is particularly
useful for avoiding nontargeted muscles or other structures. In addition, US can ensure
that the injectate stays in the targeted muscle and does not migrate to posterior pharyn-
geal muscles.
Thoracic Outlet Syndrome
TOS is a group of disorders caused by impingement of neurovascular structures in one
of several locations including the interscalene groove, costoclavicular groove, or the
space behind the pectoralis minor muscle. Symptoms can be vasogenic, neurogenic
or both and may be caused by impingement of neurovascular structures by the sur-
rounding muscles (Figure 16.9). BoNT has been reported to reduce pain and claudica-
tion symptoms. US guidance has been reported and is used by a number of clinicians
performing these procedures (31–33). Given that the “high risk” scalene muscles (near
to the carotid artery, brachial plexus, and apex of the lung) are frequently injected, US
guidance may reduce the risk of the procedure and increase the accuracy of muscle tar-
geting. Using US, typically in a transverse view, the scalene muscles and the interven-
ing trunks of the brachial plexus are visualized at the interscalene groove. In plane and
out of plane approaches are used and the muscles, brachial plexus and neurovascular
structures are localized. The needle is advanced to the target muscles with real-time
imaging. When using an out of plane view or approach, the clinician should main-
tain the tip of the needle under the transducer to avoid puncturing deeper structures
including the lung.
Figure 16.10 Transverse view, SCM
distal.

16. US-GUIDED NEUROTOXIN (BONT) INJECTIONS
165
OTHER MUSCULOSKELETAL AND PAIN APPLICATIONS
Reports of the antinocioceptive effects of neurotoxins has led to the investigation of
BoNT for a variety of musculoskeletal pain conditions including arthritis associated
joint pain (19,20,30–32,39–43), pelvic pain, back pain/sciatica, piriformis syndrome
(16,20,44) , trigger points, lateral epicondylosis (45–51), plantar fascitis (52,53), brux-
ism/ temporomandibular joint (54–56), and others. Because of its advantages over other
imaging guidance techniques, US guidance is rapidly becoming the most commonly
used guidance technique for musculoskeletal procedures and is used by physicians
from a variety of medical and surgical subspecialties. The use of US guidance for
BoNT procedures for pain is a natural extension of this experience with US guidance
(17,18,20,43,45,50,57–61).
GASTROINTESTINAL AND GENITOURINARY APPLICATIONS
Gastrointestinal
BoNT for gastrointestinal (GI) applications is currently “off label” in the United States.
Gastroenterologists have investigated BoNT interventions for a wide variety of GI prob-
lems including achalasia, chronic constipation due to outlet obstruction, injection of the
antrum of the stomach for obesity, anal fi ssure pain, and others. US guidance is used
for many of these procedures. For GI disorders, the clinical effect of toxin therapy is on
reducing muscle overactivity or reducing muscle contraction. Anticholinergic effects of
toxins in reducing secretion are also a benefi cial toxin-related effect.
Genitourinary
BoNTs are used in clinical practice for a wide variety of genitourinary (GU) applica-
tions including detrussor/sphincter dyssynergia, overactive bladder, interstitial cys-
titis, and benign prostatic hypertrophy (60–74). OnabotulinumtoxinA is approved for
the treatment of detrussor overactivity due to neurologic causes with a maximum
dose of 200 Units (36). Phase III clinical trials are ongoing for the treatment of idio-
pathic overactive bladder and Phase II clinical trials for the treatment of benign pros-
tatic hypertrophy (36).
The effi cacy of BoNT in reducing bladder detrussor and sphincter overactivity is
directly related to the anticholinergic effects on muscle contraction. The causes of benign
prostatic hypertrophy include smooth muscle hypertrophy, as well as glandular enlarge-
ment around the urethra. Stimulation of the parasympathetic nerves that innervate the
prostate leads to the release of acetylcholine resulting in smooth muscle contraction
and increased glandular secretion. BoNT is postulated to reduce the symptoms of pros-
tatic hypertrophy by reducing glandular secretion and blocking of smooth muscle con-
traction. Over time, there is atrophy of smooth muscle leading to reduced sized of the
prostate and decreased obstruction to urine fl ow. US guided techniques are described
and frequently used for detrussor, sphincter, and prostatic injections, frequently using a
trans-rectal US-guided approach (69–74).

ULTRASOUND-GUIDED CHEMODENERVATION PROCEDURES
166
SUMMARY
BoNT in clinical practice continues to expand with new indications that encompass
numerous body systems. Regardless of the body system or structure to be injected,
accuracy and precision is desirable. While some muscles and structures may be iso-
lated using conventional techniques such as palpation, EMG or E-Stim, these tech-
niques may not be adequate for other muscles or nonmuscular targets. Real-time US
guidance provides the information required to accurately inject these targets including
the location and depth of the intended target and structures to be avoided. This preci-
sion reduces the inherent risks of these procedures. Additional studies are needed to
determine whether the use of US guidance leads to increased effi cacy and a reduction
of toxin dose. While the use of US guidance for chemodenervation procedures requires
learning a new set of skills, these skills enhance patient safety and reduce the risk of
these invasive procedures.
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Trunk
Katharine E. Alter and John L. Lin
OVERVIEW
Diagnostic and therapeutic nerve blocks (NB) and motor point blocks (MPBs) and botuli-
num toxin (BoNT) injections have been used for decades to manage symptomatic muscle
hypertonia in patients with spasticity. Prior to the use of the BoNTs, neurolytic agents
(phenol, alcohol) were widely used because they provided long lasting reduction of
symptomatic or problematic muscle overactivity in patients with spasticity. Because of
their ease of use and relatively low risk/side effect profi les, many physicians now con-
sider BoNT as the fi rst choice agent for chemodenervation procedures. Despite this, neu-
rolytic agents continue to have a role in spasticity management and physicians should be
familiar with these agents and the methods required for their delivery (Table 17.1).
Although accurate targeting is important for all chemodenervation procedures, pre-
cise localization is particularly important for NBs and MPBs. Accurate delivery of these
agents is required not only for effi cacy but also necessary to reduce the potential risks
and complications that are inherent to these procedures. Traditionally, clinicians have
utilized a variety of localization techniques for chemodenervation procedures including
anatomic reference guides, palpation, electromyography (EMG) and electrical stimula-
tion (E-Stim) (1,2). More recently visual guidance techniques such as fl uoroscopy and
ultrasound (US) guidance have been used as add-on techniques or in combination with
one or more of the above techniques (3–5). US is now considered standard practice for
17
Ultrasound Guidance for Nerve and
Motor Point Blocks
Table 17.1 Relative advantages and disadvantages of BoNT versus Phenol/alcohol nerve/motor point
blocks
Advantages
Disadvantages
BoNT
Phenol/Alcohol
BoNT
Phenol/Alcohol
Ease of use
Specifi city
Few side effects
Cost of agent
Immediate onset
Fewer injection sites
Can reinject/booster
dose
Duration of action
Cost
Relatively short
duration
Multiple injection sites
Cannot reinject for 12
weeks
Procedure more diffi cult
Painful to inject
Muscle scarring/fi brosis
Precise localization required
Unselective agent
- Motor, sensory
Parasthesias
Dysesthesias
Sedation required for children

17. ULTRASOUND GUIDANCE FOR NERVE AND MOTOR POINT BLOCKS
171
many clinicians who perform nerve blocks (3,6,7). The advantages and disadvantages
of these various injection guidance techniques are discussed elsewhere in this text. This
chapter will focus specifi cally on techniques for US-guided nerve blocks.
NERVE BLOCKS
The fi rst reported reference to US guidance for nerve blocks was in 1985 to guide celiac
plexus alcohol blocks (8), for nerve blocks (4) in 1992 and for BoNT injections in 1996 for the
evaluation of the esophagus post BoNT treatment of a patient with achalasia (9). A recent
MEDLINE search for US-guided nerve blocks and BoNT injections revealed over 800 arti-
cles on nerve blocks and nearly 50 articles referencing US guidance for BoNT injections.
Since the 1980s, US has been used to guide a variety of procedures including anes-
thetic, diagnostic, and therapeutic nerve blocks. The safety and effi cacy of US localiza-
tion for nerve blocks is well established and is considered standard practice by many
physicians who perform these procedures (10–22).
TECHNIQUE FOR E-STIM-GUIDED NERVE BLOCKS
When using E-Stim for nerve blocks (without US guidance), the site for needle insertion
is selected based on anatomical landmarks, reference guides, and or surface E-Stim.
When using surface stimulation, the stimulator is positioned in the region of interest.
Stimulation is then applied and the stimulator repositioned is applied to obtain a twitch
response in the desired muscle group(s). The surface stimulator is removed, the site is
marked, and a Tefl on-coated monopolar injecting needle electrode is attached to the
stimulator. Sterile or clean technique is utilized and the needle is inserted through the
skin and directed to the anticipated site for injection (Figure 17.1). To minimize the zone
of stimulation surrounding the needle tip, a pulse width of 0.2 to 0.5 ms and a stimula-
tion intensity of 5 to 10 mA is recommended to start. As the needle is advanced, and
the twitch response is observed the stimulation intensity is adjusted, then reduced as
the needle is advanced while maintaining a twitch response. The neurolytic agent is
then injected once a twitch response is obtained in the desired distribution at a stimula-
tion intensity of 0.2 to 0.3 mA. This technique uses the minimal stimulation intensity
required to maintain a maximal twitch response which by some ensures a near nerve
location (1,2) (See discussion below).
Similar techniques are described for motor point localization and injection. A num-
ber of anatomical motor point reference guides have been published to aid motor point
localization (1,2,23–34).
LIMITATIONS OF E-STIM WHEN PERFORMING NERVE BLOCKS
Experience with US-guided nerve blocks has led clinicians to call in to question the
use of E-Stim, alone, for nerve/motor point localization. Using US to visualize needle

ULTRASOUND-GUIDED CHEMODENERVATION PROCEDURES
172
location during nerve blocks, Umey and Perlas independently demonstrated a lack
of consistent motor response with using nerve stimulation technique, even with
needle placement in physical contact with the nerve (35,36). Without US guidance
to confi rm the near nerve needle location, clinicians may continue to stimulate and
advance the needle leading to inadvertent intraneural needle placement increasing
the risk of nerve injury or intraneural injection (35,36). Bigelesien used US to evalu-
ate all patients complaining of parasthesias during axillary nerve block procedures.
Using US he checked needle placement and the location of the injectate during the
procedure and reported that in 85% of patients complaining of parasthesias at least
one nerve had been punctured. He also reported that in 81% of patient the injectate
location was intraneural, rather than in the desired perineural location. On clinical
follow up at 6 months, he reported no permanent nerve damage. This conclusion
must be questioned as no electrodiagnostic studies were performed to confi rm nor-
mal nerve function, symmetric to the uninjected limb, following the procedure or at
6 months (37).
When using E-Stim for nerve blocks, clinicians often use a technique wherein they
reduce the stimulation as they advance the needle (as described above), believing this
confi rms a near nerve location. It has been shown that lowering of the electrical current
while maintaining a maximal motor response does not correspond to approximation of
a specifi c distance to a nerve (Al-Nasser). Although intraneural injection is not conclu-
sively linked in all patients to clinical or electrophysiological injury (38–40), the fi ndings
of increased effi cacy, effi ciency with US guidance (40,41) and questions of safety with
E-Stim leave many clinicians to question which technique is best.
US-GUIDED NERVE/MOTOR POINT BLOCKS
(WITH OR WITHOUT E-STIM, EMG)
US is fast becoming the standard of care for anesthetic nerve blocks and is also increas-
ingly used for chemodenervation procedures (3–20). While nerves are easily visualized
Figure 17.1 Ultrasound localization of
femoral nerve.

17. ULTRASOUND GUIDANCE FOR NERVE AND MOTOR POINT BLOCKS
173
using a 12 to 15 MHz transducer, motor points are not currently visible even with ultra-
high frequency transducers. That being said US remains useful for MPB, as in nerve
blocks, to avoid nontargeted structures, vessels and to trace the motor nerve as distal
as possible. US guidance is often combined with EMG and E-Stim and is reported to
provide a more accurate assessment of the location and proximity of the needle to the
target nerve (19,20,42–44).
Indications for US-guided nerve blocks are similar to those for nerve blocks without
US guidance. Indications include long-term neurolysis for chronic spasticity control,
selective motor branch blocks for neurotoxin sparing spasticity intervention, temporary
regional nerve blocks (for manipulation, prior to procedures/casting). Ultrasound is
also useful when performing diagnostic blocks to differentiate static (contractures) ver-
sus dynamic hypertonia associated with an upper motor neuron syndrome. In addition
to the above noted benefi ts of US guidance for nerve blocks, an added benefi t of its util-
ity is evident in cases in patients where anatomical localization techniques and E-Stim
confi rmation are made diffi cult by anatomical rearrangements, contractures, or trauma,
and in cases where risk of vascular injury and bleeding is increased; for example, hemo-
philiac or anticoagulated patients. It must be remembered that most nerves targeted for
chemodenervation procedures are closely approximated by large vessels.
TECHNIQUE FOR US-GUIDED NERVE BLOCKS
The basic principles described for US-guided BoNT chemodenervation procedures,
discussed in detail elsewhere in this text, apply when performing US-guided nerve
blocks (45). The optimal transducer frequency ranges from 12 to 15 MHz. Higher fre-
quencies are less useful as higher frequencies do not allow adequate depth penetra-
tion to provide details of the motor nerves of interest (Figures 17.2 and 17.3). These
nerves are most often deeply seated within other tissues and cannot be visualized
with ultrahigh frequency transducers (Figure 17.4). Similarly, lower frequencies are
often of limited use due to insuffi cient resolution to distinguish nerves from sur-
rounding tissues, which may have similar echotexture (e.g., tendons). That being
said, a lower frequency transducer (5–12 MHz) may be needed for deep nerves or in
obese patients.
Applying fundamental anatomic knowledge of nerve location, course and direction, a
scout or localization US scan of the area of interest is fi rst performed (2,45). This prelim-
inary scan is essential to identify muscles, tendons, vessels, in the region as well as the
presence of anatomic variations. The information provided by this scan is required for
procedural planning and to select the optimal site for needle insertion. This site is that
which provides the most direct path of the needle to the target nerve(s) while avoiding
vessels or other nontargeted structures (Figure 17.5) (18–20, 45, 46).
When using US for nerve localization for nerve blocks, it is important to note that
the nerves often accompany or run with blood vessels within a neurovascular bundle
(46). Knowing this, Color Doppler scanning can be performed (Figure 17.6). With this
technique, the vessels can easily be distinguished from adjacent nerves, which may
appear similar on B Mode images. Nerves also often coexist with or run amidst tendons
(Figures 17.7 and 17.8). On static scans, particularly in transverse view, tendons often
have similar appearance to nerves. Tendons and nerves can be discriminated by differ-
ences in echotexture and anisotropy. Nerves are less anisotropic than tendons. On longi-
tudinal scans, with active range of motion, tendons will be observed to move more than

ULTRASOUND-GUIDED CHEMODENERVATION PROCEDURES
174
the adjacent nerves (45,46). See “Ultrasound Properties of Tissues” for full description
of these differences and similarities.
BENEFITS OF US GUIDANCE FOR NERVE BLOCKS
Ultrasonographic visualization of nerves to aid guidance during nerve blocks has been
shown to reduce the time to adequate blockade and improve the effects of the injec-
tion/block (12,13,40–42,44,47–49). US guidance has also been reported to decrease time
Figure 17.2 Transverse B-Mode view,
12–5 linear transducer, tibial and fi bu-
lar nerves, proximal popliteal fossa.
Figure 17.3 Color Doppler, 12–5 linear
transducer, longitudinal view, tibial
nerve popliteal fossa.

17. ULTRASOUND GUIDANCE FOR NERVE AND MOTOR POINT BLOCKS
175
required for the procedure (47,49,50) and the amount of injectate needed to achieve
equal effi cacy (51).
Further studies are needed to support or refute whether US alone versus a US–E-
Stim technique is superior for nerve blocks. In an effort to improve the accuracy of and
reduce the risk of nerve blocks many clinicians currently use a combined technique.
Combined guidance is supported by evidence indicating that evoked motor responses
may be absent during E-Stim even when the needle electrode is in direct nerve contact
(35,36). Another factor to be considered is that when using E-Stim, the zone of stimula-
tion/depolarization surrounding the needle electrode may be quite large. This occurs
Figure 17.4 B-Mode 12–5 linear trans-
ducer. Transverse view, proximal, sci-
atic nerve.
Figure 17.5 B-Mode, 12–5 linear
transducer, transverse view proximal
thigh/inguinal crease. Femoral ves-
sels, nerve, muscles.

ULTRASOUND-GUIDED CHEMODENERVATION PROCEDURES
176
when high current stimulation is required to obtain a motor response (1,52). This creates
a large area of stimulation/depolarization reducing the accuracy of nerve localization
with E-stim. Considering these and other factors, some clinicians have concluded that
E-Stim alone provides insuffi cient guidance for nerve blocks, particularly when using
sclerosing agents such as phenol or alcohol.
Evidence to date, related to combined US–E-Stim guidance for nerve blocks is varied.
This may be in part due to variations in technique and study design. Some investigators
report no difference in clinical response following nerve blocks employing a combined
Figure 17.6 Color Doppler, trans-
verse view, 12–5 linear transducer.
Obturator nerve and vessels.
Figure 17.7 B-Mode, 12–5 linear trans-
ducer, longitudinal view, wrist.

17. ULTRASOUND GUIDANCE FOR NERVE AND MOTOR POINT BLOCKS
177
US–E-Stim technique (53–56). Other investigators report limited clinical benefi t and
increased clinical burden when adding E-Stim to US-guided blocks (57). In addition to
the benefi ts of reducing time for procedures and improved block effi cacy, Rothe reported
added benefi t to using combined E-Stim–US guidance for axillary nerve blocks. Rothe
reported that when using US guidance, E-Stim provided added benefi t in localizing the
nerve. He also reported that US guidance was required to identify surrounding anatom-
ical landmarks and avoidance of vasculature, that is circumfl ex humeral artery (58).
One reported benefi t of US guidance for nerve blocks is the potential for reduced risk
of nerve injury (59). However, neural injury has been reported even when both E-stim
and US are employed for nerve injections (56,60). Additional studies are required to
prove or refute the argument of improved safety for procedures employing combined
US and E-Stim for nerve blocks.
While more studies are needed, combined procedures do appear to provide value,
particularly for clinicians who are novice to US scanning (7,40,41). In light of the above
studies showing an absent motor response despite near nerve location, clinicians must
use caution when advancing needles through unfamiliar tissues. The lack of motor
response is not a guarantee of safe needle advancement or location, nor does a local
motor response delineate a nearby motor point from a stimulated nerve.
MOTOR POINT BLOCKS
Chemodenervation MPB procedures using neurolytic agents are an alternative to nerve
block MPBs, which require isolation of the motor end plate area of the muscle and
require E-Stim and or EMG to guide the procedure. MBPs involve isolation of the motor
endplates either with EMG (listening for endplate noise) or E-Stim, using the technique
described above (1,2,57,61). Motor points generally occur in bands or specifi c zones of
muscle and are not evenly spread throughout the muscle (23–33). The location of the
motor point zone varies between individual muscle groups. A number of anatomic ref-
erence guides have been published which can aid physicians in performing these proce-
dures. The choice of spasticity management employing MPB or nerve blocks is in part
based on the experience and training of the physician. Many physicians choose MBP
Figure
17.8 B-Mode, 12–5 linear
transducer, transverse view, distal
wrist, carpal tunnel.

ULTRASOUND-GUIDED CHEMODENERVATION PROCEDURES
178
to reduce the risk of parasthesias/dysesthesias, which can be seen with nerve blocks
involving mixed nerves with an extensive sensory distribution (e.g., median nerve).
AGENTS FOR NERVE AND MOTOR POINT BLOCKS
There are two broad categories of agents used for nerve blocks, those that provide a rel-
ative short duration of action (1–6 hours) and those providing longer duration of action
(6-–18 months) (Table 17.2) (1,2,62). Short acting agents are generally used for proce-
dural support (casting, etc.) or for diagnostic blocks as described above. A diagnostic
block using a short acting local anesthetic agent may also helpful for treatment planning
and will distinguish between muscle over activity or hypertonia and contracture. Long
acting agents are used to provide reduced muscle tone and improved passive and active
function over many months.
Short Acting Agents
Short duration nerve blocks are performed using local anesthetic agents including
bupivacaine, etidocaine, and lidocaine. These agents are used for their relatively short
duration, local anesthetic effects on sensory and motor nerves. Local anesthetics work
Table 17.2 Comparing chemodenervation agents
BoNTs
Local Anesthetics
Phenol
Ethyl Alcohol
Site of action
Neuromuscular
junction
Nerve/motor point
Nerve/motor point
Nerve/motor point
Physiologic
effect
Blocks release of
acetylcho-
line and other
neurotransmitters
Blocks sodium chan-
nels and thereby
nerve action
potentials
Protein denaturation
Demyelination,
Wallerian
degeneration
Protein denaturation
Demyelination,
Wallerian
degeneration
Selectivity
Highly selective
motor block
Unselective
Sensory, motor
Unselective
sensory, motor
Unselective
sensory, motor
Duration of
action
3 to 4 months
1 to 6 hours
6 to 18 months
6 to18 months
Administration US/EMG/E-Stim
US/EMG/E-Stim
US/EMG/E-Stim
US/EMG/E-Stim
Sedation
May be needed
for some pediatric
patients
Needed for most
pediatric patients
Needed for most pedi-
atric patients
Needed for most
pediatric patients
Precision of
localization
Must be in correct
muscle, close to
motor point may
be preferred
Requires precise
localization of nerve
or motor point
Requires precise
localization of nerve
or motor point to
prevent tissue
damage
Requires precise
localization of nerve
or motor point
to prevent tissue
damage

17. ULTRASOUND GUIDANCE FOR NERVE AND MOTOR POINT BLOCKS
179
by reducing ion channel permeability and block sodium channels thereby reducing or
blocking nerve depolarization/conduction (62–66). These short acting agents produce
no long lasting or permanent effect on motor or sensory nerves and induce no tissue
destruction. The duration of action is determined by the lipid solubility of the specifi c
agent and whether the agent is combined with epinephrine. Epinephrine increases
the duration of action by inducing vasoconstriction and reducing blood fl ow to the
areas (62).
Although epinephrine increases the duration of action of local anesthetics, peripheral
nerve blocks are generally performed with local anesthetic agents alone, that is, with-
out epinephrine. This is because epinephrine may induce intense vasoconstriction and
carries a risk of nerve or tissue ischemia, particularly when injected in the distal limb
(62,63,65).
Other risks associated with local anesthetic blocks include hypersensitivity or aller-
gic reactions, cardiopulmonary events, and systemic effects if the agents enter the gen-
eral circulation. Because of the risks of cardiopulmonary events, emergency supplies
and clinicians trained to address these issues should be available for support. These
agents should be used with care in patients with hepatic insuffi ciency or G6PD defi -
ciency. Literature supports a low risk of neural toxicity with perineural local anesthetic
injections (62,65).
Local Anesthetic Agents
Lidocaine hydrochloride is an aminoethlyamide and is available in dilutions of 0.5% to
4%, with and without epinephrine. For nerve blocks, solutions of 0.5% to 2% without
epinephrine are more often used. Although, as noted above, epinephrine often doubles
the duration of the nerve block most physicians chose solutions without epinephrine to
reduce the risk of nerve/tissue injury from vasoconstriction/ischemia. The onset of action
of lidocaine is prompt (3 minutes) and the blockade is intense. The duration of blockade
depends in part on local blood fl ow, the concentration and total dose, as well as the accu-
racy of the block. Duration, without epinephrine may generally last at least 60 minutes.
Total dose of lidocaine without epinephrine should not exceed 4.5 mg/kg (2,62).
Etidocaine and bupivacaine hydrochloride produce an intense blockade of sen-
sory and motor nerves. The duration of the blockade is 2 to 3 times longer than that
induced by lidocaine. For this reason many physicians choose these agents for diagnos-
tic nerve or MPBs. Etidocaine is available in 1% to 1.5% solutions and a maximum dose
< 6 mg/kg is recommended. Etidocaine reportedly provides a more selective motor
blockade (66). Bupivicaine is available in solutions of 0.25% to 0.75% and a total dose
< 3 mg/kg, is recommended (62).
Chemoneurolysis with Phenol and Ethyl Alcohol
When used for nerve or MPBs, phenol and alcohol produce long lasting reduction in
muscle tone (2,3,62,64,67–71). These agents reduce spasticity or muscle tone by induc-
ing protein neurolysis and resulting Wallerian degeneration of nerves and motor points.
Aqueous solution of phenol at 3% to 7% and ethyl alcohol (hereafter “alcohol”) of 30%
to 45% are typically used. Alcohol at lower concentrations (5%–10%) acts as a local anes-
thetic agent. Phenol and alcohol have both been successfully used for many years with

ULTRASOUND-GUIDED CHEMODENERVATION PROCEDURES
180
excellent results in reducing unwanted muscle tone. The choice of agent is generally
institution or clinician driven, but phenol is more commonly used. Because of the scle-
rosing nature of these agents, precise localization of motor nerves and motor points is
required when using phenol or alcohol. The importance of precise localization cannot
be overstated and is required to reduce the risk of injury to tissues that may occur when
they are inadvertently injected (2,45,62,67). Injection of phenol and alcohol is quite pain-
ful. The pain from the agent itself, as well as from the E-Stim used during the procedure
requires general sedation for most pediatric patients. This need for sedation represents
a signifi cant disadvantage for these agents (compared with BoNT) in high risk compro-
mised pediatric patients.
Phenol: In adults a maximum dose of 1 gm/day should not be exceeded. In children
the recommended maximum dose is ≤ 30 mg/kg or 1 gm/day. For example, 10 ml of a
4% solution contains 0.4 gm of phenol or 25 ml of a 5% solution contains 1 gm. These
doses are well below the reported lethal range of 8.5 gm in adults and 0.1 to 0.2 g/kg in
children (62,71–74).
Adverse effects of phenol and alcohol include direct effects produced by protein dena-
turation induced by these agents including damage to surrounding tissues and sensory
nerves. Patients may complain of postprocedural pain, parasthesias, and chronic dyses-
thesia. When compared to phenol blocks, there are relatively few reported complications
with alcohol blocks. This may be due to the agent safety profi le, due to the fact that phe-
nol is much more commonly used than alcohol or both (62,67). Reported complications
following phenol injections also include local, regional, and systemic effects. Vascular
complications can occur including necrosis of small arterioles and deep vein thrombosis
(DVT). Overdose can cause central nervous system (CNS) depression, and seizures.
SUMMARY
Nerve and MPBs provide long-lasting effective relief from spasticity and other
forms of muscle overactivity associated with upper motor neuron syndrome and
other conditions. Although BoNT therapy has largely replaced these agents in many
practices, these procedures and agents continue to play an important role in patient
care. As such, physicians should be familiar with these procedures and the localiza-
tion techniques required to perform these blocks. The role of US guidance for these
procedures continues to expand and physicians should be well versed in this tech-
nique because of its potential for added benefi t and reduced risks when performing
nerve blocks.
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(Trang không có chữ)

PART IV
Anatomic and Procedural Atlas
Nicole A. Wilson and Katharine E. Alter
S
ince one of the most important aspects of learning to use
ultrasound guidance for chemodenervation is developing
an understanding of the pertinent anatomy, this section was
designed to aid the clinician in reviewing the appearance of
that anatomy under ultrasound. Each sub-section is organized
around an anatomic division and then organized from proximal
to distal within that division. Muscles are highlighted with a
sketch of the relevant anatomy and a clinical photo demonstrat-
ing the position of the ultrasound transducer and the injection
technique most often used for that muscle. The facing page
shows an unaltered ultrasound image illustrating the typical
view of that muscleand the same image with the relevant anat-
omy highlighted for ease of identifi cation. In some cases the
same muscle has been illustrated with both a longitudinal and a
transverse view under ultrasound.
This anatomic atlas should prove invaluable for all clinicians
who are performing chemodenervation procedures, not just those
who are utilizing ultrasound guidance. Videos corresponding to
many of the still images are provided on the accompanying DVD.
The DVD version of this Atlas also includes additional video
materials, both ultrasounds and clinical videos, to illustrate alter-
native approaches.
Head and Neck 186
Trunk 220
Upper Limb 222
Hand 284
Lower Limb 298

186
ANATOMIC AND PROCEDURAL ATLAS
HEAD AND NECK
Risorius
Origin:
Fascia over masseter muscle
Insertion:
Skin at the corner of the mouth
Innervation: Facial nerve (CNVII)
Action:
Retracts corner of the mouth

HEAD AND NECK
187
Splenius Capitis (Longitudinal View)
Scalenes
Splenius Capitis (Longitudinal View)
Scalenes
HEAD AND NECK
187

188
ANATOMIC AND PROCEDURAL ATLAS
HEAD AND NECK
Masseter
Origin:
Zygomatic arch and maxillary process of zygomatic bone
Insertion:
Lateral surface of ramus of mandible
Innervation: Masseteric nerve (branch of V3)
Action:
Elevation of the mandible

HEAD AND NECK
189
Splenius Capitis (Longitudinal View)
Scalenes
Splenius Capitis (Longitudinal View)
Scalenes