Ultrasound-Guided Chemodenervation Procedures

391
HIP
HIP
Adductor Brevis - Injection

392
MUSCLE LAYERS AND INJECTION POINTS ATLAS
Adductor Longus - Injection
HIP

393
HIP
HIP
Gracilis - Injection

394
MUSCLE LAYERS AND INJECTION POINTS ATLAS
Adductor Magnus - Injection
HIP

395
HAMSTRINGS
HAMSTRINGS
Muscle Layers
Biceps Femor
Semitendinosus
Semimembranosus

396
MUSCLE LAYERS AND INJECTION POINTS ATLAS
Muscle Layers
HAMSTRINGS
Biceps Femor
Semitendinosus
Semimembranosus
Biceps Femor
Semitendinosus
Semimembranosus

397
HAMSTRINGS
HAMSTRINGS
Semitendinosus - Injection

398
MUSCLE LAYERS AND INJECTION POINTS ATLAS
Biceps Femoris - Injection
HAMSTRINGS

399
HAMSTRINGS
HAMSTRINGS
Semimembranosus - Injection

400
MUSCLE LAYERS AND INJECTION POINTS ATLAS
Muscle Layers
LOWER LEG
Gastrocnemius
Soleus
Tibialis Posterior
Flexor Hallucis Longus
Flexor Digitorum Longus
Gastrocnemius
Soleus
Tibialis Posterior
Flexor Hallucis Longus
Flexor Digitorum Longus

401
LOWER LEG
LOWER LEG
Muscle Layers
Gastrocnemius
Soleus
Tibialis Posterior
Flexor Hallucis Longus
Flexor Digitorum Longus
Gastrocnemius
Soleus
Tibialis Posterior
Flexor Hallucis Longus
Flexor Digitorum Longus

402
MUSCLE LAYERS AND INJECTION POINTS ATLAS
Gastrocnemius - Injection
LOWER LEG

403
LOWER LEG
LOWER LEG
Soleus - Injection

404
MUSCLE LAYERS AND INJECTION POINTS ATLAS
Tibialis Posterior - Injection
LOWER LEG

405
LOWER LEG
LOWER LEG
Flexor Digitorum Longus - Injection

406
MUSCLE LAYERS AND INJECTION POINTS ATLAS
Flexor Hallucis Longus - Injection
LOWER LEG

407
POSTERIOR NECK/BACK
POSTERIOR NECK/BACK
Muscle Layers
Splenius Capitis
Levator
Trapezius

408
MUSCLE LAYERS AND INJECTION POINTS ATLAS
Muscle Layers
POSTERIOR NECK/BACK
Splenius Capitis
Levator
Trapezius
Splenius Capitis
Levator
Trapezius

409
POSTERIOR NECK/BACK
POSTERIOR NECK/BACK
Trapezius - Injection

410
MUSCLE LAYERS AND INJECTION POINTS ATLAS
Splenius Capitis - Injection
POSTERIOR NECK/BACK

411
POSTERIOR NECK/BACK
POSTERIOR NECK/BACK
Levator - Injection

(Trang không có chữ)

Acoustic enhancement: Increased echo intensity or brightness of the image of
structures deep to a structure that has little attenuation to US waveforms for example,
fl uid fi lled cyst.
Acoustic impedance: Acoustic Impedance = Density of Tissue × Speed of Sound in
Tissue. Impedance is created by the resistance of the imaged tissues to the US/sound
waves. Impedance is determined by both the speed of sound as well as the density of
imaged tissues/structures. The impedance of different types of tissues varies leading
to differing tissue characteristics observed on US images. This allows discrimination
of dissimilar structures when scanning. In the human soft tissues, the average speed of
sound is approximately 1,540 meters per second, with an approximate range for 1,400
meters per second to 1,640 meters per second.
Air has a very low impedance yet blocks ultrasound and causes shadowing rather
than enhancement. Clear fl uid, such as that found in a cyst, has few refl ectors within it
to absorb, scatter, or refl ect US. The residual energy of US passing through clear fl uid is
greater than that of adjacent tissues. Greater energy results in stronger echoes. Stronger
echoes cause the tissues beneath the fl uid to appear brighter than the adjacent tissues, as
if lit by a fl ashlight. Scattering, absorption, and refl ection = attenuation.
Acoustic Power (Transmit Power): The amount of energy generated by the transducer
is acoustic power, which is expressed in Watts. The transmit/power control varies the
amount of energy transmitted by the transducer to the patient. This should be adjusted
to the lowest level required to produce an acceptable image.
Acoustic shadowing: Reduced or no echo intensity of structures deep to tissue that
strongly refl ect or attenuate ultrasound, for example bone.
Aliasing: Artifact encountered in Doppler imaging. Aliasing occurs when sampling fre-
quency (pulse repetition frequency [PRF]) is less than 2 X that of the assessed Doppler
shift. This occurs because of a marked frequency shift with high velocity blood fl ow com-
bined with a high transducer frequency and/or low PRF. Aliasing results in ambiguous
measurement of high frequency Doppler shifts. Decreasing the transducer frequency or
increasing the Doppler angle can correct aliasing. Adjusting the spectral Doppler base-
line can be used to eliminate the confusing appearance of aliasing, but does not actually
eliminate or correct it.
Amplitude: Height or strength of the sound waves, measured in decibels (dB).
Anechoic: Devoid of echoes, that is, structure is completely black/dark. For example,
bile is anechoic.
Anisotropy: A characteristic of some tissues in which the echogenicity of the structure is
affected by the incidence/angle of the US beam. At 90° the tissue (or a needle) appears
hyperechoic. At angles less than 90° the tissue appears artifactually hypoechoic. This
may mimic pathology, such as tendinopathy or a tendon tear. Some tissues are highly
anisotropic, that is, tendon and connective tissues are more anisotropic than nerves
which are more anisotropic than muscle.
Glossary

GLOSSARY
414
Artifact: Image features seen during an US exam that do not correlate with the true
nature of the structure or tissue. Examples include: acoustic enhancement, acoustic
shadowing, anisotropy, reverberation, etc.
Attenuation: Refers to the decrease in US intensity occurring as US waves pass
through tissue and are absorbed, scattered, or refl ected. Ultrasound energy is atten-
uated progressively along the course of its travel from transmission to reception. There is a
near linear relationship between frequency and attenuation such that higher frequencies are
progressively fi ltered out as the sound beam travels. Approximately 0.5 decibels of attenua-
tion occurs per MegaHertz for each centimeter the beam travels (1 dB/cm/MHz of refl ector
depth).
The higher the frequency of the sound wave, greater the attenuation. Attenuation
decreases the amount of ultrasound energy transmitted and refl ected to and from deeper
tissues, respectively, thereby reducing the visualization of deeper structures. This effect
is similar that experienced during needle electromyography (EMG) whereby the audi-
ble signal from distant motor units is of lower frequency than motor units directly under
the needle recording electrode. Soft tissues act as a high frequency fi lter absorbing high
frequency sound waves. Attenuation is measured in db/cm.
Axial: Depth axis.
B-Flow: NonDoppler format whereby blood fl ow is displayed in grayscale. Useful to
show fl uid fl ow and to distinguish between dynamic fl ow and thrombus. Not suscep-
tible to aliasing. B-Flow is a patented GE and works by digital subtraction of B-mode
images, no Doppler involved.
B-Mode (Brightness Modulation): Modern B-mode imaging consists of a series of rap-
idly collected still frames to produce a cinematic, real time, scanning experience. B-mode
is routinely used for diagnostic US and procedural guidance. Intensity (amplitude) of
echoes is converted to grayscale images where brightness is proportionate to returning
echo strength. Intensity (amplitude) of echoes is converted to grayscale images where
brightness is proportionate to returning echo strength.
Beam: Acoustic fi eld directed and produced by transducers.
Beam Steering: The US beam is electronically directed right or left during imaging.
Steering enhances needle visualization and may reduce anisotropy.
Boundary: The tissue plane created by two structures or tissues. That is, fascial planes
between various muscles, vessels, nerves, organs.
Cineloop: A temporarily stored sequence of ultrasound pictures or frames available for
review and or permanent storage after the US machine is placed in the “freeze” mode
that allows real-time imaging.
Color Doppler: Colorized image representation of blood fl ow created by the computer
processor. Utilizes the Doppler effect, see below. The convention in Color Doppler/
Vascular Doppler imaging is Red = signals moving toward the transducer, Blue = sig-
nals moving away from the transducer. Color Doppler is often used to identify/avoid
vessels during procedures and to check for blood fl ow in a vessel.
Coupling agent: A material that reduces the US impedance at skin:transducer inter-
face. Usually a water-based gel. In the absence of gel, saline may be used as a
substitute.

GLOSSARY
415
Cycle: A complete sound wave (1 Hz). The mechanical ultrasound wave is produced in
response to vibration of a piezoelectric crystal. For diagnostic/procedural guidance, the
frequency ranges from 2 to 18 MHz (106 Hz).
Decibel (dB): Unit of measure expressing the amplitude intensity of sound waves.
Depth Gain Compensation (DGC): Controls (Slide Pots) that compensate for attenua-
tion (loss) of sound as it passes through tissues.
Doppler/Doppler Effect/Shift: Doppler Effect occurs when the refl ected signal (wave-
form) from a moving target is different than the original transmitted signal. When US
waveforms are transmitted to and refl ected from stationary targets, the transmitted/
returning wavelengths are the same. US waves refl ected back to a transducer from a
moving target will have a different frequency from the transmitted frequency. If the
refl ector (moving target) is moving toward the transducer, the refl ected frequency will
be higher than the transmitted frequency. The opposite is true of refl ectors moving away
from the transducer. For example, The pitch of an emergency siren increases as the vehi-
cle approaches you, then decreases as it travels away from you. See Color Doppler,
Duplex Imaging, Power Doppler.
Damping Material: A component of transducer construction, which functions to shorten
ultrasound pulses by decreasing the ring-time (continued vibration of the transducer
crystals). Shorter ring times produce shorter US pulses, which equate to wider band-
widths. The wider the bandwith, the wider the frequency rand of a transducer.
Duplex Imaging: Displays Doppler waveform and grayscale/B-mode image
simultaneously.
Dynamic Focusing: Is continuous reception focusing. Dynamic focusing is built into
most US equipment. It doesn’t change frame rate.
Dynamic Range: Relates echo amplitude to grayscale. It represents the range of signals
that can be processed by the US system, measured in dB. Low dynamic range settings
produce high contrast, black and white images, whereas high dynamic range settings
produce low contrast images with multiple shades of gray.
Electronic Focusing: One or more focal zones can be set and positioned by the operator
to enhance imaging of target structures. Setting multiple focal zones reduces the frame
rate.
Far Field (Fraunhofer Zone): The depth where the transmitted beam begins to diverge
marks the beginning of the far fi eld.
Focal Zone: The depth at which resolution is highest. Focal zone position is, in part,
determined by sound wave frequency, crystal size/shape, and fi xed transducer fac-
tors. Modern US equipment allows what operator to electronically adjust the position
of a focal zone or add multiple focal zones to optimize imaging. Spatial resolution will
improve, but temporal resolution will be degraded by using multiple focal zones.
Focusing: Narrows the US beam to increase detail of the image within the narrowed
section. Also allows the US beam to be focused at a certain depth. The goal of focusing is
improved resolution. Most modern US systems use electronic focusing, not lens focus-
ing. See Dynamic Focusing.
Footprint: The portion of the transducer placed in contact with the patient.

GLOSSARY
416
Frame Rate: Frequency per second that an image is refreshed in real-time imaging.
Frame rates vary between US machines and with individual system settings including
focal zone, depth, image width, and preprocessing settings.
Frequency: Frequency is the number of complete sound waves per second. In clinical
ultrasound this is measured in megahertz (MHz; 106 Hz).
Freeze Frame: Control setting that stops or freezes the image to be captured and saved/
printed. After prolonged pauses between operational use, most machines will automat-
ically freeze the image.
Gain: Regulates the echo amplifi cation or brightness of an image. Gain is adjustable
and controlled by the operator by increasing or decreasing echo amplifi cation to opti-
mize imaging. Gain adjustment allows differential amplifi cation of returning echoes
from structures at various depths. Weaker echoes from deeper tissue (far gain) require
more amplifi cation than echoes returning from superfi cial tissues (near gain). Overall
gain adjusts the gain of the entire image. Time Gain Compensation (TGC)/Depth Gain
Compensation (DGC): Controls (Slide Pots) that compensate for attenuation (loss) of
sound as it passes through tissues.
Heel-Toe: A technique where the transducer is rocked along its long axis. This technique
is utilized during imaging to steer the US beam to optimize the image and a reduce
anisotropy.
Hyperechoic: Highly echogenic or bright.
Hypoechoic: Relatively few echoes return to the transducer resulting in an image that
is dark.
Imaging Planes:
Coronal: Or frontal plane. Frontal plane is a vertical plane that divides the body
into ventral (front) and dorsal (back) sections.
Sagittal: Or median or longitudinal plane that divides the body into right and left
sections through the midline. The term parasagittal plane is sometimes used to
describe a vertical plane, which is not at the midline. Many anatomists consider
this term unnecessary as by defi nition sagittal plane refers to any vertical plane
cutting the body into right/left sections, not just a mid line cut.
Transverse: The transverse or horizontal or axial plane is a plane cutting the body
in to superior and inferior sections.
Interface: Occurs where two tissues with different acoustic properties meet or are in
contact.
Impedance: See Acoustic Impedance.
In-Plane Needle Insertion: The needle is inserted along the length of the transducer.
In this view, the entire length of the needle will be visualized as it is inserted through
the US beam. It is essential to maintain a fl at or shallow angle of the needle relative to
the transducer to maintain the view of the needle. At acute angles, the needle view may
be lost. This often requires that the needle be inserted at some distance away from the
transducer and requires a tangential path to the target. Because this may be a less direct
path to the target, it may require a longer needle.

GLOSSARY
417
Interference Pattern: Distortion of echo pattern due to refl ection of echoes from adjacent
tissues or US refl ectors. Results in image artifact called speckle, which may be reduced
compound imaging.
Linear Array: A long, rectangular shaped transducer of varying size with the piezo-
electric crystals arranged side by side producing a rectangular image. Linear transduc-
ers are used for the majority of musculoskeletal imaging and imaging of small parts,
superfi cial structures. A hockey stick is a smaller foot print linear transducer useful for
imaging small body parts particularly those with irregular surfaces.
Longitudinal Scan: Scanning along the length of a structure. For example long axis
view of muscle, abdomen, vessel, and so on.
Long Axis of Transducer: Correlates to the length of the transducer face.
M-Mode/Motion Mode: US image is displayed as a continuous display on the horizon-
tal axis of the monitor. Used primarily in cardiology to tract cardiac and valve motion.
Used in MSK/Neuro research to track contraction or shortening velocity of a muscle.
Mixed Echo-Texture: Image structure contains a mix of hyper and hypoechoic echoes.
The image characteristics may vary with the imaging plane, that is, transverse or longi-
tudinal image of a structure. For example, muscle.
Near Field (Fresnel Zone): The region of the ultrasound beam that begins at the trans-
ducer crystal and then progressively converges until it ends at the narrowest part of the
US beam, the focal zone. (See Far Field).
Out of Plane Needle Insertion/Injection: The needle is inserted across the short axis of
the transducer. The needle is visualized as a hyperechoic dot. CAUTION: When using
this technique, take care to keep the tip of the needle under the ultrasound beam so as
not to lace the needle tip in an untargeted location or structure. To assist localization/
visualization use a “walk down technique”, see below.
Overall Gain: A control on the US machine that adjusts the gain (brightness) of the
entire image.
Piezoelectric Crystal: Converts electrical potentials into mechanical vibrations and vice
versa.
Piezoelectric Effect: Property of some crystals in which the crystals change shape when
an electrical fi eld is applied or when the crystals are mechanically stressed. Piezoelectric
crystals convert electrical pulses to mechanical waves and vice versa.
Pulse Repetition Rate: Times per second that transmit–receive cycle occurs.
Refl ection: US waves change direction when they refl ect off an object or tissue inter-
faces. The refl ected waveforms cannot be transmitted to deeper structures. Specular
refl ectors are tissue refl ectors, which in relation to the US waves are smooth and mir-
ror like. Example, blood vessel walls. Specular refl ectors are best viewed perpendicular
to the sound beam, as they will cause sound to be refl ected away from the transducer
not viewed straight on. Refl ectors of sound, depending on the angle of the US beam,
may refl ect all or a proportion of the transmitted US beam. Nonspecular refl ectors are
“rough,” producing nearly equal refl ections when viewed from any angle.
Reverberation Artifact. Reverberation occurs when US waves refl ect back and forth
between two strong refl ectors. This may result in multiple images of the same structure.

GLOSSARY
418
Needles and bones are two common sources of reverberation artifact seen in musculo-
skeletal sonography.
Resolution: Ability to distinguish two different interfaces or structures. Resolution is
directly proportional to frequency of the sound wave.
Rocking: Also referred to as toggling. In this maneuver, the transducer is rocked or
tilted back and forth on its short axis. This is used to optimize imaging of a structure by
steering the US beam. This technique is also used to reduce anisotropy.
Scattering: Occurs as the US waves bounce (refl ect/refract) while being transmitted
through tissues. Scattering occurs off of refl ectors which are smaller than the US wave-
length, or larger refl ectors with rough surface. When scattering occurs, less energy, that
is, fewer vibrations are returned to the transducer which degrades image quality.
Short Axis: Transducer: correlates to the width of the transducer face.
Specular Refl ectors: Tissue refl ectors which, in relation to the US waves, are smooth sur-
faces at right angles to the sound beam large. For example, blood vessel walls. Refl ectors
of sound, depending on the angle of the US beam, may refl ect all or a proportion of the
transmitted US beam.
Stand-Off Pad: Gel pad or other material that increases the distance between the sur-
face of the skin and the transducer. Enhances imaging of superfi cial structures with little
overlying subcutaneous fat, that is, skin, hand, face. In lieu of a stand-off pad, gel can be
mounded up and the transducer fl oated on the mound to increase the distance between
the transducer and the skin.
Time Gain Compensation (TGC): Controls (Slide Pots) that compensate for attenuation
(loss) of sound as it passes through tissues (Synonymous with Depth Gain Compensation
[DGC]).
Toggling: Also referred to as rocking and involves rocking the transducer on its short
axis. This is used to steer the US beam to optimize the image and reduce anisotropy.
Transducer/Probe: An array of piezoelectric crystals embedded in a linear, curvilinear,
or other arrangement, surrounded by a housing, connected to the computer via a cable.
Transducers determine the frequency of the US waveforms and therefore the depth of
penetration of the sound waves and resolution of the image. Most transducers do not use
a single frequency, they contain piezoelectric crystals that create a range of frequencies
(e.g., 5–12 MHz, 3–5 MHz). Diagnostic imaging and or procedural guidance typically
requires more than one transducer. Transducers of varying shapes, sizes, and frequen-
cies allow imaging at different depths. Transducers are connected to the US machine
via a cable. NOTE: Transducers are expensive and fragile and therefore should be
handled with care. When cleaning a transducer, it is advisable to follow manufactur-
er’s recommendations. Most manufacturers recommend a nonalcohol-based cleaner.
Isopropyl alcohol may damage the transducer by drying the membrane.
Transducer Covers: Sterile sheath that covers the transducer, and a portion of the cable.
Used for some procedures and injections. They may be purchase separately or in a pro-
cedure kit, which includes sterile gel.
Transmit Power (Acoustic): Expressed in watts. The transmit/power control varies the
amount of energy transmitted by the transducer to the patient. This should be adjusted
to the lowest level required to produce an acceptable image.

GLOSSARY
419
Transverse Scan or Section: Imaging at a 90° to the long axis. The term “transverse
scan or view” is most often used when imaging the abdomen, neck, or muscles. May be
referred to as an axial scan when imaging the brain.
Ultrasound Beam: The width/length of the beam is determined by the transducer. The
beam is generally narrower than the transducer. This creates an image, which is a nar-
row slice with a small fi eld of view. This is overcome by moving the transducer to image
an entire structure or using Extended Field of View Imaging. The operator may steer
the beam by rocking or toggling the transducer. Electronic beam steering is present on
many newer machines.
Velocity (of Sound Waves): Speed of ultrasound waves. Sound cannot travel in a vac-
uum. Velocity in human tissues ranges from 1,500 to 1,600 and is averaged or stan-
dardized in human tissues at 1,540 mps. Standardization is required for time-distance
measurement coeffi cients.
Walk Down Technique: A strategy to aid visualization of the needle tip when using the
out of plane needle insertion technique. Once through the skin, the clinician angles the
needle toward the plate of the US beam (“Wall”) aiming toward the region superfi cial
to the target. When the tip of the needle is fi rst seen as a bright dot, forward motion of
the needle is stopped. The needle is then withdrawn slightly and angled deeper. This
process is repeated until the needle is “walked down the wall” into the target.” Gently
vibrating or jiggling the needle while it is advanced aids visualization. Using this tech-
nique the tissue directly surrounding the needle will move or vibrate helping to confi rm
the position of needle.
Wavelength: The length of one full cycle of US wave. Wavelength is inversely propor-
tional to frequency. Frequency/wavelength determines the resolution and depth of pen-
etration of sound waves.

(Trang không có chữ)

abnormal discharges, 28
abobotulinumtoxinA preparation, 11
acetylcholine, 46
acoustic impedance, 62
on density and speed of sound, 63
of different tissues, 64
acoustic power, 103
acoustic wave. See sound wave
acoustics, 56
active range of motion (AROM), 155
activities of daily living (ADL), 39
adductor brevis, injection points, 391
adductor longus, injection points, 392
adductor magnus, injection points, 394
adductor pollicis brevis, 288–289
adductors, 306–307
ADL. See activities of daily living
AGP. See anatomic guidance and palpation
ALARA. See As Low As Reasonably Achievable
alcohol. See ethyl alcohol
amyotrophic lateral sclerosis (ALS), 48
anachoic Baker’s cyst, 125
anatomic guidance and palpation (AGP), 138–140
for cervical muscles, 142
muscle identifi cation, 139
muscle location/depth estimation, 139–140
UMN syndromes, 140, 141
anatomic planes, 113
annotation control, 96
anterocollis, 25
AROM. See active range of motion
As Low As Reasonably Achievable (ALARA), 72
attenuation
coeffi cients, 71
frequency dependence of, 71
of sound, 70
of sound energy, 62
axial resolution, 77, 78, 89
B-mode (brightness mode), 90–91
curvilinear transducer, gluteal region, 92
linear transducer posterior calf, 91
back, injection points, 407–411
beam steering, 104, 120, 121
beamformer, 75, 78
BFM scale. See Burke-Fahn-Marsden scale
biceps/biceps brachii, 126
longitudinal view, 246–247
transverse view, 248–249
biceps femoris, injection points, 398
Blue Phantom, 111
body markers, 105
bone, 134–135
BoNT. See botulinum neurotoxin; botulinum toxin
booster injections, 7
BOTOX®, 10
botulinum neurotoxin (BoNT), 2, 24
booster injections, 7
botulinum toxin, 2
Clostridium botulinum, 2
commercial products, 5
composition of commercial, 5
FDA approved uses, 7
female Swiss-Webster mice, 5
intrafusal muscle fi bers, 5
muscle and spindles, 4, 5
neuromuscular junctions, 2
properties of commercial, 6
protein structure, 3
SNARE proteins, 2, 3
synaptic release, 2
synaptic release mechanism and blockade, 4
therapy for muscle hypertonia, 42–43
toxin, 3
types and SNARE proteins, 5
botulinum neurotoxin injections (BoNT injections), 28,
41, 154. See also chemodenervation procedures
adverse events, 149
brachial plexus transverse view, 163
in CD, 26
GI applications, 165
GU applications, 165
head and neck, 161–162
localization techniques, 155
lower limb injections, 157–161
musculoskeletal and pain applications, 165
pain indications, 162–164
patient selection, 154
upper limb injections, 155–157
US vs. anatomic guidance, 140, 142–143
botulinum toxin (BoNT), 10, 22, 46
adults, 49–50
advantages and disadvantages, 170
injection, 18, 30
Index
Note: Italicized page references denote atlas sections of the book.

INDEX
422
botulinum toxin (BoNT) (cont.)
injection uses, 170
medication, 10
patients with motor neuron disease, 50
pediatric patients, 50
type A, 11
botulinum toxin therapy (BoNT therapy), 48
focal dystonia, 122
head and neck, 122
lower limb injections, 122
primary onset focal dystonia, 122
upper limb injections, 120
UMNS, 122
brachialis, 244–245
brachioradialis
injection points, 372
longitudinal view, 250–251
transverse view, 252–253
brightness mode. See B-mode
broadband source, 73
bupivacaine hydrochloride, 179
Burke-Fahn-Marsden scale (BFM scale), 24
camptocormia, 20, 22
cardiac specialty transducers, 89
CD. See cervical dystonia
central nervous system (CNS), 32
injury of, 36
lesions, 38
cerebral lesions, 38
cerebral palsy (CP), 31, 41, 140
cervical dystonia (CD), 24, 162, 163, 164
agonist and antagonist muscle groups, 24
antagonistic activity, 24–25
BoNT, 24
BoNT injections in, 26
clinical evaluation, 24
injection technique and muscle targeting, 24
medications, 24
onabotulinumtoxinA, 25
primary dystonic deviation, 25
with SCM injections, 25–26
sternocleidomastoid, 25
treatment, 25
cervical muscles
EMG guidance for, 142
US guidance for, 162
chemodenervation procedures, 43, 101, 118. See also
ultrasound guidance (US guidance)
agent comparison, 178
AGP, 138–140, 141
BoNT injections and nerve blocks, 108
localization techniques, 108
localization techniques, 170
phenol and alcohol, 42
scanning environment, 109, 110
US guidance vs. anatomic techniques,
140, 142–143
US scanning/procedural guidance, 108
US-guided BoNT, 173
Clostridium botulinum, 2
CNS. See central nervous system
Color Doppler Scanning, 173, 174, 176
complex regional pain syndrome (CRPS), 31
compound imaging, 82
compressional wave, 58–59
computed tomography (CT), 56, 87
congenital myopathy, 130
contrast resolution, 79–80
controls operated by clinician, 101
acoustic power, 103
beam steering, 104
body markers, 105
capturing/storing images/cine-clips, 104
depth control, 101
dual image, 105
focal zone, 103
frame rate, 103
freeze frame, 104
gain control, 102
measurement tools, 105
needle or biopsy guide, 105
time gain compensation, 102–103
CP. See cerebral palsy
CRPS. See complex regional pain syndrome
CT. See computed tomography
curvilinear transducer, 88
DBS. See deep brain stimulation
deep brain stimulation (DBS), 33
deltoid, 127, 232–233
depth control, 101, 102
depth gain compensation (DGC), 102–103
DGC. See depth gain compensation
diagnostic ultrasound transducer, 73
Doppler imaging
color Doppler ultrasound image, 93
Doppler effect, 91
posterior calf transverse, 93
dorsal interossei, 284–285
drooling, 49
dual image selection, 105
DYSPORT®, 11
dystonia
causes, 32
effects on musculoskeletal system, 40
features, 30–31
generalized, 32

INDEX
423
idiopathic, 32
idiopathic focal hand, 16
isolated, 20
lateral trunk, 21
mirror, 17
nonfocal lower limb, 33
patterns of involvement, 31–32
posttraumatic, 31
primary, 30
proximal muscles, 16
secondary, 30, 34
segmental, 17, 18, 32
sustained or intermittent postures, 30
task specifi city, 16
upper extremity, 16, 17
dystonic tremor, 25
E-Stim. See electrical stimulation
E-Stim-guided nerve blocks, technique for, 171
ear, nose, and throat (ENT), 85
ectopic discharges, 28, 180
elastography, 82–83
electric high-low table, 110
electrical stimulation (E-Stim), 108, 138, 170
for chemodenervation, 146
limitations of, 171, 172
for nerve blocks, 171
electromyography (EMG), 22, 25, 50, 108
electromyography guidance
(EMG guidance), 142. See also ultrasound guidance
(US guidance)
for cervical muscles, 142
limitations, 145
machine, 144
nerve stimulator, 147
in passive EMG recording, 143
signal amplifi er, 144, 147
elevational resolution, 79
EMG. See electromyography
EMG guidance. See electromyography guidance
endocavity transducers, 98
ENT. See ear, nose, and throat
ephaptic transmission, 28
etched needle, 120
ethyl alcohol, 179
effects, 180
role, 170
etidocaine, 179
extensor carpi radialis, 276–277
extensor digitorum communis, 274–275
extensor hallucis longus
longitudinal view, 334–335
transverse view, 332–333
extensor indices proprius, 278–279
extensor pollicis brevis, 282–283
extensor pollicis longus, 280–281
face, injection points
anterior, 342–343
side, 344–346
FDA. See Food and Drug Administration
FDS. See fl exor digitorum superfi cialis
fi bularis brevis, 330–331
fi bularis longus, 328–329
fi eld of view (FOV), 84, 109
extended, 80, 98
limited, 80
fi rst dorsal interosseous, 286–287
fl at piston transducer, 61
fl exor carpi radialis
injection points, 374
longitudinal view, 254–255
transverse view, 256–257
fl exor carpi ulnaris, 262–263
injection points, 377
fl exor digitorum brevis, 338–339
fl exor digitorum longus, 326–327
injection points, 405
fl exor digitorum profundus, 264–265
injection points, 378
fl exor digitorum superfi cialis (FDS), 128, 142
injection points, 376
longitudinal view, 266–267
transverse view, 268–269
fl exor hallucis brevis, 336–337
fl exor hallucis longus, injection points, 406
fl exor pollicis longus, 270–271
fl oating transducer, 121
focal dystonia, 33, 122, 158
focal zone, 103, 104
Food and Drug Administration (FDA), 7
forearm, injection points, 369–379
forward bending. See camptocormia
FOV. See fi eld of view
freestanding CRT monitors, 86
freeze frame, 104
gain control, 102
gastrocnemius, 127
injection points, 402
lateral head, 316–317
medial head, 318–321
gastrointestinal applications (GI applications), 85, 165
genitourinary applications (GU applications), 85, 165
glands, 135
glenohumeral joint
anterior view, 222–223
posterior view, 224–225

INDEX
424
GMFCS. See Gross Motor Function Classifi cation
System
gracilis, injection points, 393
Gross Motor Function Classifi cation System
(GMFCS), 146
GU applications. See genitourinary applications
hamstrings, injection points, 395–399
heel-toe maneuvers, 116
Hemifacial spasm (HFS), 28
abnormal discharges and pathologic
manifestations, 28
BoNT focal injection, 28
ectopic discharges, 28
facial nerve vascular compression, 28
using onabotulinumtoxinA, 28
oral treatment, 28
surgical treatment, 29
HFS. See Hemifacial spasm
high–low examination tables, 110
hip, injection points, 379–394
hip fl exors, 158, 159, 160
iliacus, 159
iliopsoas, 158
piriformis syndrome, 159, 160
psoas, 158
hockey stick transducer, 97
human muscle tissue, 124
Huygens–Fresnel principle, 60
hyperhidrosis, 46
hypothenar muscles, 296–297
idiopathic focal hand dystonia, 16
Botulinum toxin injection, 18
neuropathies, 16, 17
nonpharmacologic therapies, 17
oral medications, 17
symptom, 16
Writer’s cramp, 16, 17
iliacus, 159, 302–303
iliopsoas, 304–305
injection points, 386
image resolution, 75
axial resolution and dependence, 77, 78
contrast resolution and dynamic range, 79–80
elevational resolution, 79
image contrast, 75, 76
lateral resolution and dependence, 78, 79
processing steps, 76
spatial resolution, 75
ultrasound frequency and relationship to, 76–77
image-guided procedure techniques, 108
in-plane approach (IP approach), 116
chemodenervation procedures, 118, 119
IP US-guided BoNT injections, 119
using lower frequency transducers, 118
needle long axis and view, 117
needle orientation, 117, 118
needle travel, 118
posterior reverberation artifact, 117
incidence angle, 64
incobotulinumtoxinA, 7, 11
intensity, 58
intrafusal muscle fi bers, 5
IP approach. See in-plane approach
joints, 135
lateral axial deviation, 22
lateral pterygoid, 194–195
lateral resolution, 78, 79, 89
laterocollis, 25
latissimus dorsi, 228–229
leg, injection points
lower, 400–406
levator, injection points, 366, 411
levator scapulae, 210–211
lidocaine hydrochloride, 179
ligaments, 132
linear transducers, 88, 89
array transducers, 97
foot print, 90
lower extremity injections, 140–142
longissimus capitis, 198–199
longus capitis, 212
longus colli, 214–215
lower limb dystonia (LLD), 30. See also idiopathic focal
hand dystonia
CRPS, 31
DYT1 and DYT5, 30
focal or task-specifi c dystonia, 33
idiopathic dystonia, 32
medical and surgical interventions, 30
neurotoxin therapy, 34
nonfocal lower limb dystonia, 33
patient evaluation, 32
patterns of involvement, 31–32
physician practice patterns, 31
primary and secondary, 30
psychogenic causes, 30
secondary dystonia, 34
lower limb injections, 122, 157, 158. See also upper limb
injections
focal dystonia, 158
hip fl exors, 158, 159, 160
hip girdle and pelvic muscles, 158
iliacus at ASIS, 159
iliopsoas, distal at inguinal crease, 159

INDEX
425
posterior calf, 160–161
UMN syndromes, 158
lumbricals, 290–291
M-mode (motion mode), 91
ultrasound image, 92
magnetic resonance imaging (MRI), 56
Manual controls Phillips, 102
MAS. See Modifi ed Ashworth Scale
masseter, 126, 188–189
measurement tools, 105
mechanical index (MI), 72
medial pterygoid, 192–193
megahertz (MHz), 57
methicillin-resistant staphylococcus aureus (MRSA), 93
MHz. See megahertz
MI. See mechanical index
migraine, 163
minor drooling, 19
Modifi ed Ashworth Scale (MAS), 140
Modifi ed Physician Rating Scale (mPRS), 140
Modifi ed Tardieu (MT), 140
Modifi ed Tardieu Scale (MTS), 146
motion mode. See M-mode
motor disorder, 36
motor neuron disease, patients with, 50
motor point blocks (MPBs), 177–178
chemoneurolysis, 179–180
injection uses, 170
MPBs. See motor point blocks
mPRS. See Modifi ed Physician Rating Scale
MRI. See magnetic resonance imaging
MRSA. See methicillin-resistant staphylococcus aureus
MSK system. See musculoskeletal system
MT. See Modifi ed Tardieu
MTS. See Modifi ed Tardieu Scale
muscle
abnormalities, 129
anachoic Baker’s cyst, 125
architecture, 124, 125
biceps, 126
congenital myopathy, 130
deltoid, 127
gastrocnemius, 127
hyperechoic and hypoechoic echotexture, 125
hypertonia, 38
hypoechoic, 128, 129
masseter, 126
neurogenic atrophy, 130
normal muscle, 130
pennated, 126
rectus femoris, 128, 130
semimembranosis, 127, 128
tibialis anterior, 127
triceps and FDS, 128
uniform echotexture of parotid gland, 126
musculoskeletal system (MSK system), 84
dystonia effects, 40
equinus gait and cerebral palsy, 39
and pain applications, 165
rheologic changes in muscle, 39
skin breakdown and hip dislocation, 40
upper limb posturing and cerebral palsy, 38
musician’s cramp, 16
MYOBLOC®, 12
narrowband source, 73
neck, injection points
front, 347–357
posterior, 407–411
side, 358–368
needle guide, 105
nerve blocks. See also motor point blocks (MPBs)
agents, 178
chemodenervation agent comparison, 178
combined US–E-Stim guidance, 176, 177
E-Stim limitations, 171, 172
lidocaine hydrochloride, 179
short acting agents, 178, 179
technique for E-Stim-guided, 171
US guidance for, 170, 171
nerves, 132
brachial plexus, 133
longitudinal scanning, 132
US scanning, 133
neurogenic atrophy, 130
neuroimaging, 33
neurolytic agents, 170
neuromuscular junctions, 2
neurotransmitters, 2
nonalcohol-based wipes, 94
obliquus capitis lnferioris, 196–197
ODS. See Output Display Standard
omohyoid, injection points, 368
onabotulinumtoxinA, 10, 163
OP approach. See out of plane approach
out of plane approach (OP approach), 119, 120
advantage, 119
disadvantage, 119
technique, 119
Output Display Standard (ODS), 72
pain indications, BoNT therapy for, 162
pain/headache, 163
cervical dystonia, 163, 164
migraine, 163
TOS, 164

INDEX
426
palmaris longus, injection points, 373
panoramic imaging, 80, 81, 82
pantothenate kinase-associated neurodegeneration
(PKAN), 33
parotid gland, 216–217
post injections, 162
passive range of motion (PROM), 155
pathologic manifestations, 28
pectineus, injection points, 390
pectoralis minor, 234–235
longitudinal view, 236–237
transverse view, 238–239
pediatric abdomen transducer, 88
penetration depth, 90
phenol, 42, 179
effects, 180
role, 170
Phillips IU 22 controls, 101
Physician’s Rating Scale (PRS), 146
piriformis, 298–299
piriformis syndrome, 159, 160
pisa syndrome. See lateral axial deviation; lateral
trunk dystonia
platysma, injection points, 360
PKAN. See pantothenate kinase-associated
neurodegeneration
poly-vinyldine-difl uoride (PVDF), 73
posterior calf, 160–161
premium ultrasound systems, 72
procedural supplies, 94, 95
PROM. See passive range of motion
pronator quadratus, 260–261
pronator teres, 258–259
injection points, 375
PRS. See Physician’s Rating Scale
psoas, 158, 300–302
pulse echo imaging transducers, 73
PVDF. See poly-vinyldine-difl uoride
radiofrequency (RF), 75
receive beamforming. See receive focusing
receive focusing, 74
rectus abdominis, 220–221
rectus femoris, 128, 130
distal, 314–315
injection points, 385
proximal, 312–313
retrocollis, 25
RF. See radiofrequency
rimabotulinumtoxinB preparation, 12
risorius, 186–187
rocking. See toggling
saliva, 48
salivary glands, 48
accurate targeting of, 50–51
AGP and US guidance, 143
minor, 48
sartorius, injection points, 383
scalenes, 208–209
scalenus anterior, injection points, 363
scalenus medius, injection points, 364
scalenus posterior, injection points, 365
scanning modes
B-mode/brightness mode, 90–91
doppler imaging, 91
M-mode/motion mode, 91
3D/4D modes, 92
scanning supplies
procedural supplies, 94, 95
stand-off pads, 94
transducer cleaner, 94
US supplies, 93, 94
Selective Motor Control (SMC), 146
semimembranosis, 127, 128, 310–311
injection points, 399
semitendinosus, 308–309
injection points, 397
sialorrhea, 48
adults, 49–50
BoNT therapy, 48, 49
causes, 48
normal salivation, 48
oral motor control, 49
patients with motor neuron disease, 50
pediatric patients, 50
salivary glands accurate targeting, 50–51
US properties, 51
SMC. See Selective Motor Control
SNARE proteins, 2
soleus, 322–323
injection points, 403
sophisticated processor, 84–85
sound, 56
attenuation of, 70
speed, 57–58
sound interaction with tissue
acoustic impedance and density, 63, 64
attenuation of sound, 70
frequency dependence, 71
properties, 62
refl ection and refraction, 63, 64, 65, 66
safety considerations, 72
scattering and dependence, 67, 68, 69
speckle formation and, 69–70

INDEX
427
sound wave, 56
frequency, 57
intensity, 58
sound energy, 56–57
speed, 57–58
wavelength, 58
speckle, 70
spinal lesions, 38
splenius capitus
injection points, 367, 410
longitudinal view, 206–207
transverse view, 204–205
stand-off pads, 94, 95, 121
sterile transducer, 93
sternocleidomastoid
injection points, 362
longitudinal view, 202–203
transverse view, 200–201
stretch refl exes, 36
stroke, 41
submandibular gland, 218–219
supinator, 272–273
synaptic release, 2, 4
synaptobrevin, 2
TBI. See traumatic brain injury
Tefl on-coated EMG injection needles, 120
temporal resolution, 90
temporalis, 190–191
tendons, 129
fl exor tendons/median nerve at wrist, 130
instability, 131
longitudinal view, 131
median nerve in wrist, 131
neovascularity quadriceps, 132
US appearance of, 129
tensor fascia lata, injection points, 384
Terason controls, 101, 102
teres major, 230–231
TGC. See time gain compensation
thenar muscles 1, 292–293
thenar muscles 2, 294–295
thermal index (TI), 72
thoracic outlet syndrome (TOS), 162, 164
3D imaging, 80, 81
TI. See thermal index
tibialis anterior, 127
tibialis posterior, 324–325
injection points, 404
time gain compensation (TGC), 75, 102–103
toggling, 116
Toronto Western Spasmodic Torticollis Rating Scale
(TWSTRS), 24
TOS. See thoracic outlet syndrome
transducer/needle orientation
in-plane approach, 116–119
initial scot scan, 116
optimize viewing of needles, 120
out of plane approach, 119, 120
during real-time US-guided procedures, 116
ultrasound biopsy guide, 121
transducers, 112
axial resolution, 89
cleaner, 94
correct grip/hold of, 114
curvilinear transducer, 88
depth of penetration, 90
extended fi eld of view, 98
frequency, 97
handling, 112, 114
holding, 98, 99
incorrect grip/hold on, 114
lateral resolution, 89
linear, 88, 90
linear and cardiac specialty, 89
marked side, 114
moving/scanning with, 101
orientation, 99–100, 114, 115, 116
pediatric abdomen, 88
resolution, 87, 88
selection, 97, 112, 114
specialty, 98
temporal resolution, 90
3D transducer, 89
transesophageal, 99
unmarked side, 115
transmit beamforming. See transmit focusing
transmit focusing, 74
transmit power, 103
transvaginal/rectal transducer, 99
trapezius, 226–227
injection points, 361, 409
traumatic brain injury (TBI), 31, 41
triceps/triceps brachii, 128
longitudinal view, 240–241
transverse view, 242–243
truncal dystonia. See also lower limb dystonia (LLD)
Botulinum toxin, 22
camptocormia, 20
camptocormia and lateral axial deviation, 22
causes, 20
dystonic back extension, 21
lateral trunk dystonia, 21
severe truncal or axial dystonias, 22
trunk twists and bends, 20
weak antagonist muscles, 20

INDEX
428
TWSTRS. See Toronto Western Spasmodic Torticollis
Rating Scale
ultrasound (US), 25, 51, 57, 108
advantages and disadvantages, 108, 109
beam formation, 59, 60
beam steering, 104
biopsy guide, 121
body markers, 105
capturing/storing images/cine-clips, 104
chemodenervation procedures, 108
depth control, 101
dual image, 105
education and training, 105
educational resources, 106
Esaote MyLab US unit, 86
extended fi eld of view, 98
focal zones, 103
frame rate, 103
freeze frame, 104
gain control, 102
imaging systems, 84
limitations of, 109
machine operation and knobology, 95, 96, 97
machine preset/set up, 97
measurement tools, 105
modern systems, 84
needle or biopsy guide, 105
patient data entry screen, 96
patient/physician prepartion/positioning, 110
Phillips IU 22 US machine, 85
positioning machine/screen, 110, 111
procedural guidance, 94, 95, 108, 109
properties of tissues, 111
scanning, 90–92, 109, 110, 111–116
scattering, 68
stand-off pads, 94
supplies, 93, 94
technology, 84
Terason 3200 and cart/mobility system, 87
time gain compensation, 102–103
transducer cleaner, 94
transducer/needle orientation, 116–120
transducers, 87–90, 97–101
transmit or acoustic power, 103
US unit/machine, 85, 86
ultrasound guidance (US guidance), 170, 171
benefi ts for nerve blocks, 174, 175, 176, 177
evaluation of chemodenervation effects, 149
for nerve blocks, 171
real-time assessment, 149
and reduced adverse events, 149–150
reported reference to, 155
salivary glands, 143
US localization of femoral nerve, 172
ultrasound imaging technology, 56
bony interface and shadowing, 65
compound imaging, 82
compressional wave, 58–59
diagnostic, 60
elastography, 82–83
fl at piston transducer, 61
Huygens–Fresnel principle, 60
image resolution and image contrast, 75, 76
MRI and CT imaging, 56
normal incidence and deviation, 66
panoramic imaging, 80, 81, 82
processing steps, 76
pulsed echo imaging, 60, 61, 62
reverberation artifact from needle, 66
sound interaction with tissue, 62–72
specular refl ections, 67
technologies, 80
3D imaging, 80
ultrasound beams formation, 59, 60
vibration sonoelastography image, 83
ultrasound instrumentation
array transducers and focusing, 73–74, 75
diagnostic ultrasound equipment, 72
piezoelectric materials, 73
pulsed echoes and bandwidth, 73
transducer, 72, 73
ultrasound image production, 75
ultrasound scanning (US scanning), 95, 124
anatomic planes, 113
bone, 134–135
glands, 135
joints, 135
ligaments, 132
muscle, 124–129
nerves, 132–133
other tissues, 136
phantom image with vessel, 111
procedural guidance, 111, 112
techniques for scanning, 116
tendons, 129–132
transducer orientation, 114, 115, 116
transducer selection and handling, 112, 114
transducer/needle orientation, 116–120
ultrasound training phantom, 111
US display screen, 115
vessels, 133–134
UMNS. See upper motor neuron syndrome
upper extremity injections, 142
combined US and E-STIM guidance, 147
combined US:EMG guidance, 145–146
E-Stim for, 146
E-STIM vs. US guidance, 146

INDEX
429
US and E-STIM and nerve blocks, 148
US evaluation of effects, 149
US vs. EMG guidance, 143–146
US-guided, 148–149
upper limb injections, 120, 155, 157
focal dystonia, 122
focal upper limb dystonias, 155, 156–157
head and neck, 122
longitudinal scan, fl exor arm, 156
lower limb injections, 122
primary onset segmental or focal dystonia, 122
transverse scan fl exor muscles, 156
UMNS, 122, 157
upper motor neuron syndrome (UMNS), 33, 36, 122, 154
acquired hand deformity, 140, 141
BoNT therapy for muscle hypertonia, 42–43, 44
casting and splinting for, 41
chemodenervation, 43
CNS and spinal lesions, 38
cocontraction and sialorrhea, 140, 141
gait dysfunction, 43
muscle hypertonia, 38, 41
patient’s hypertonia, 41, 42
positive and negative signs, 37
post-stroke spasticity and motor impairments, 41
refl ex activity and muscle tone, 36
secondary impairments association, 39, 40
signs and symptoms, 36
stretch refl exes and extensor muscle tone, 36
symptomatic hypertonia, 42
treatment, 40
UMNS-related hypertonia, 36
US guidance, 161–162
US. See ultrasound
US guidance. See ultrasound guidance
US scanning. See ultrasound scanning
US-guided nerve blocks, 172, 173
B-Mode 12–5 linear transducer, 175, 177
Color Doppler Scanning, 173, 174, 176
indications for, 173
transverse B-Mode view, 174
US-guided BoNT chemodenervation, 173
VAMP. See synaptobrevin
vastus intermedius, injection points, 387
vastus lateralis, injection points, 388
vastus medialis, injection points, 389
vessels, 133–134
vibration, 57
wavelength, 58
Writer’s cramp, 16, 17
XEOMIN®, 11

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