Presented at the annual congress of the Tunisian society of Physical Medicine and Rehabilitation. Disclosure: Sponsored by IPSEN Tunisia

1. NTUH TUH

2. Ultrasound Guided Botulinum Toxin Injection
and Nerve Block for Management of
the Upper Limb Spasticity

4. Take Home Message
Ultrasound guided Nerve Block
Ultrasound guided BT injection
Basics of US guided interventions

6.  Anatomy  Dynamic scan
 Surface anatomy  Compare to the
other site
 Positioning  Vascularity
 Clear bone image  Don’t compress
 A thorough
examination
 Correlate with the
clinical
 Long Axis and Short
Axis
• Adjust machine
settings

7. Advantages of ultrasound guided interventions over
landmark based block / EMG guided injection:
1- Ultrasound guidance avoids collateral damage of
nearby vessels and other complications
2- It helps accurate placement of the injectate around
target nerve  better spasticity control.
3- Ultrasound guidance requires smaller quantities of the
injectate to achieve target.
4- Avoids injection into fibrotic parts of spastic muscle

12. Needle visualization

17. Ultrasound guided
BT injection

21. Spastic UL

22. Shoulder internally rotated and adducted
Elbow flexed and pronated,
Wrist and fingers flexed – thumb in palm

23. Shoulder

24. Internal RotationAdduction
Subscapularis
(BTX 25-50,
DSPT 100-150)
+ PLT
Pectoralis major
(BTX 60-140,
DSPT 150-300)
Latissimus dorsi
(BTX 80-160,
DSPT 150-300)
Teres major
(BTX 25-50,
DSPT 100)

29. Elbow

30. Elbow
PronatedFlexed
PT
(BTX 25-50,
DSPT 100-200)
PQ
(BTX 20-40,
DSPT 100-200)
Biceps B
(BTX 60-120,
DSPT 200-300)
Brachialis
(BTX 30-60,
DSPT 150-200)
BR
(BTX 40-80,
DSPT 100-150)

34. Wrist, fingers &
thumb

35. Thumb in palmFingers
Clenched fist
Wrist
flexion
FPL
(BTX 20-30,
DSPT 100-150)
FPB
(BTX 10-20,
DSPT 50-100)
Adductor P
(BTX 10-20,
DSPT 50-100)
OP
(BTX 10-20,
DSPT 50-100)
FDS
(BTX 20-80,
DSPT 100-200)
FDP
(BTX 20-80,
DSPT 100-200)
FCR
(BTX 40-70,
DSPT 100-200)
PL
(BTX 30-60,
DSPT 100-200)
FDS
FCU
(BTX 20-40,
DSPT 100-150)
FDP

39. Ultrasound guided
Nerve Block

40. LAEthyl AlcoholPhenol
Use long acting
+ NE  Several
hours
Contracture
vs
severe
spasticity
5-10%  LA
> 35% 
Protein
denaturation
 Axon &
Myelin damage
Long duration
1%LA
2-5%  Protein
denaturation
 Axon &
Myelin damage

41. The minimal amount of phenol used to produce
an effective block was 0.5 cc of a 2% phenol
solution. The maximum amount was 5 cc’s of a 3%
solution. Overall the average amount of phenol
solution used for each nerve block was 2 cc’s of a
2% to 3% solution of aqueous phenol.

42. Thumb in
palm
Wrist/ finger
flexion
Elbow
flexion
RCTNMN
AIN
MSCN

47. Phenol Nerve blockBTX
lowhighCost
rapiddelayedOnset
?
Nerve more
muscles
?Effect
Less easyMore easyTechnique &
skills
+-Need to
pharmacist
More seriousLess seriousComplications

49. "May the Force be with you"