ws 434 us guidance for upper limb …f45ebd178a369304538a-da09e9363888411f910f2103a3cb9db6.r58...ws...
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WS 434 US Guidance for Upper Limb Chemodenervation Procedures
AAPM&R 2015 Katharine E Alter MD
Zach Bohart MD Robert Cooper MD
Elie Elovic MD Heakyung Kim MD John McGuire MD
Michael Munin MD Jeff Strakowski MD
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Faculty/Disclosures • Katharine Alter: Royalties Demos, Honorarium NANA
• John McGuire: speaker fee Allergan • Jeff Strakowski: Royalties Demos Medical Publishing
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Handouts
• Handouts are provided online – Review of US guidance techniques for upper limb
BoNT/chemodenervation – Review of US Guidance/Physics * – Review of Evidence comparing various guidance
techniques for BoNT procedures*
• To provide adequate hands on scanning only a brief didactic review will be presented
– Please refer to the online handouts for full handouts
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Objectives
• Review of US Basics: • Physics • Scanning and Procedural Techniques
• Hands on US Training for Muscle Identification for Upper Limb Chemodenervation Procedures
• At the conclusion of the Workshop participants will – Be familiar with ultrasound appearance of key upper limb
muscles – Gain skills in US knobology/transducer handling skills – Be familiar with various US guided procedural techniques
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Course Agenda
• Introduction/Review of US Basics & Scanning Techniques/Tips: 15 minutes
• Hands on Scanning: 75 minutes – Demonstration/projection of muscle groups – Followed by practice scanning lead by table
trainers – Table trainers will rotate during the course
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Hands On Course Agenda
• US identification of muscles • Demonstration Procedural Guidance Techniques 10
– In plane and Out of plane – Rotate to this station to practice during down time
• Proximal Muscles/Nerves: – Pectoralis Major/Subscapularis/Latissimus Dorsi 15 min – Biceps/Brachialis/Brachioradialis : 15 minutes
• Forearm 20 minutes – FCR/ FCU, Pronator Teres, FDS/FDP, FPL
• Nerves 15 min
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Chemodenervation Procedures
Botulinum Toxin (BoNT) • AbobotulinumtoxinA
(Dysport) • IncobotulinumtoxinA
(Xeomin) • OnabotulinumtoxinA
(Botox) • RimabotulinumtoxinB
(Myobloc/Neurobloc)
Nerve/Motor Point Blocks • Diagnostic nerve blocks
– Local anesthetics
• Neurolytic blocks – Phenol 4-6% – Ethyl alcohol 30-50%
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Why use US for Chemodenervation Procedures?
• Correct targeting is important for – Efficacy – Minimizing risk/adverse events – Reduce the required effective
dose (potentially) • Traditional localization techniques
have recognized limitations • Comparative studies indicate that
US guidance is more accurate than other techniques
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ADVANTAGES OF US GUIDANCE FOR CHEMODENERVATION PROCEDURES
Why you should consider using US for BoNT Injections?
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US for BoNT Injections: Advantages Improved accuracy • Localization is limited by
complex or overlapping anatomy
• Very small/large patients – Difficult to estimate
muscle depth
• Identifies safest path to the target – Location – Depth
Transverse View, Proximal Forearm
Transverse View, Mid-forearm
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US for BoNT Injections: Advantages • Visualize/isolate target
structures – Quickly – Easily – Accurately
• Less painful – Smaller needles
• Pediatric patients often require no sedation
• Distract patients during procedure
US Photo from Steffen Berweck MD
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US for BoNT Injections: Advantages
• High risk targets – Avoid untargeted
• Muscles • Structures
– Vessels/nerves/organs
• High stakes muscles – SCM – Scalenes – Oromandibular muscles
• Pterygoids
– Subscapularis
Sternocleidomastoid Transverse Scan Out of Plane Injection
Adductors, Transverse Doppler
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US for BoNT Injections: Advantages
• Improved accuracy when
localization is limited by: – Involuntary muscle activity – Co-contraction – Motor control – Patient cooperation
• US does not require AROM to isolate muscle – Muscle identification is based on
pattern recognition
Upper Motor Neuron Syndromes
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US for BoNT Injections: Advantages
Focal dystonia • Identify individual muscle
fascicles – Ex: FDS digit 3 vs. 4
• Increased accuracy and speed when identifying muscle fascicles
• Reduced pain – Smaller needles
FDS longitudinal view, mid forearm Short axis view of needle
Longitudinal View, FDS
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US for BoNT Injections: Advantages
• Non-muscle targets: – Salivary Glands – Prostate
• Salivary gland: – Correct localization is
critical to reduce the risk of dysphagia
• EMG and E-Stim do not help localization of non-muscle targets
Parotid
Submandibular
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US for BoNT Injections: Advantages
• Visualize injectate – Confirms correct site – Provides info on volume of
injectate/distension of muscle
• Reduces risk of over injection at one site
– Minimize spread to adjacent muscles or structures
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US for Chemodenervation Procedures: Advantages
Nerve Blocks • Diagnostic Blocks
– Local Anesthetics
• Therapeutic blocks – Phenol – Ethyl Alcohol
Musculocutaneous Nerve
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US for Chemodenervation Procedures: Advantages
US + E-Stim for Nerve Blocks Interscalene block • US speeds the localization
of a nerve or nerve branch • Reduces risk of nerve injury • Reduces risk of tissue
damage when injecting phenol
• Reduces risk of injury to organs, vessel penetration
Video from John Lin MD, Sheppard Center
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Ultrasound and Procedural Guidance
Disadvantages • Equipment related factors
– Availability – Cost
• Clinician related factors – Lack of experience/training – Limited access to training
specific for chemodenervation – Steep learning curve
Transverse view, proximal forearm
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Ultrasound for Chemodenervation: Summary
• Localization techniques – Palpation – EMG – Nerve stimulators – Ultrasound
• All have advantages & disadvantages
• Best Strategy: – Be skilled in multiple techniques – Be aware of
– The limitations of each technique – Evidence supporting/refuting the
accuracy of the various techniques
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Comparison of Injection Techniques
Palpation EMG Stimulation Sonography
Accuracy +/- +/- + +++
Practicability + - +/- ++
Availability +/- +/- +/- +
Pain + - +/- +++
Speed +/- - +/- ++
Evaluation +/- - +/- +++
Future research - - - +++
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ULTRASOUND BASICS
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ULTRASOUND PHYSICS See online handout for review
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Ultrasound Equipment Basics:
• Soundwaves are produced by piezoelectric crystals – Cystal arrays are placed
into transducers • Transducers
– Determine the frequency of US waveform ( λ)
– Frequency of US λ determines
• Depth of penetration • Resolution of the image
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Ultrasound: Transducer Selection • Select size and shape to match
the clinical application • Size/Shape of transducer
– Linear: • Best for flat surfaces
– Curvilinear: • Best for abdomen/pelvic/GYN
– Hockey stick: • Hand • Small irregular surfaces
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US Basics: Transducer Frequency MHz Depth/Penetration Application 3 12-20 cm OB/GYN 5 12-15 cm Deep muscles 7.5 8-10 cm Leg 10 5cm Forearm 12-17 3.5- 2cm Hand, face
Select transducer to match required penetration depth • 12-17 MHz for superficial structure
– Hand, forearm • 3-5 MHz for deep muscles
– Piriformis, iliacus, quadratus lumborum • Most transducers have mixed frequencies
– 3-5, 7-12 etc
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Transducer Handling/Orientation
• To correctly orient the transducer on the patient – Look for a manufacturer’s
mark on one end of the transducer
– The marked end = screen left on display
– To confirm this orientation: • Tap the end of the
transducer to confirm the orientation
Notched end
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US Basics: View convention
• Top of image is superficial – i.e. skin
• Bottom deeper structures • Transverse view
– Conventions vary • Right always to patient right • Medial always to right
• Longitudinal view – Left proximal – Right distal
Superficial
Deep
Patient R or Medial
Patient Left or Lateral
Transverse view, flexor forearm
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US Basics: View convention
Longitudinal view Convention • Place the transducer on the
patient so that – Proximal = screen left – Distal = screen right
Qadriceps tendon and patella
Distal Proximal
Superficial
Deep
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US Basics: Transducer Orientation
Long Axis of Transducer Short Axis of Transducer
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Weak scattering from blood and fluids with low impedance to US λ Tissues will appears dark or hypoechoic
US Appearance of a Tissue is Determined by its Acoustic Impedance
“Speckle” from scattering in tissue. L~ λ
Strong echoes from “mirror-like” interfaces will appear bright or hyperechoic
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US Basics: Tissue Properties • Muscle
– Hypoechoic background (contractile elements/fascicles)
– Interspersed hyperechoic bands of fibroadipose tissue
• Long axis – CT appears as parallel
hyperechoic lines, less uniform than in tendon
• Short Axis – CT intramuscular tendons,
aponeurosis appear as bands and streaks
Transverse view
Longitudidal view
Transverse view
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Holding the transducer
• Grasp the transducer lightly using your – Thumb + index or – Thumb + index+ middle
finger – Do not over grip
• Keep hand in contact with the patient at all times to avoid slipping – Using heel of hand or 4th
and 5th finger
Incorrect : No contact with patient
Correct : Maintaining contact with patient
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Anatomic Plane/Transducer Orientation
• Be aware that the – Anatomic plane and
transducer orientation may not always match
• Example – Pronator Quadratus
Pronator Quadratus Longitudinal Muscle Scan Transverse Upper Limb Scan
Pronator Quadratus Transversel Muscle Scan Longitudinal Upper Limb Scan
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Scanning Tips/Techniques: Injection Techniques
In Plane: Needle Inserted Along Long Axis of Transducer
Out of Plane: Needle Inserted Across the Short Axis of the Transducer
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Interventional MS US: Clinical Pearls • In plane/long Axis needle view:
– Keep needle parallel to transducer – Insert needle at flat angle – Poor needle visualization
• Oblique position • Steep angle needle
• Out of plane/short axis needle view: – Keep needle tip under US beam
• If needle tip is outside of US beam, visualization is lost
• May be in untargeted structure or muscle
– Walk down technique • Follow movement of needle tip
passing through tissues planes to target
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• Real time injection • Whatever technique is
used: – Keep needle within the
ultrasound beam – If needle tip is outside of
the narrow US beam visualization is lost
• Tip may not be in target structure
Interventional MS Ultrasound: Clinical Pearls
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Interventional MS Ultrasound: Pearls of Wisdom
• Larger needles are easier to see than small needles – Larger needles hurt more – 27g needles are easily seen particularly in an in plane view – Non-insulated needles are visualized better than insulated. Etched
Needles are also available • Small amount of air (.2-.3 ml) helps define needle location • Agitate injectate: increases reflection from bubbles
– Agitating may denature the toxin • Billing: In the USA, to charge/bill for US, a picture or cine-
loop must be saved to document the procedure • Billing Code: 76942: Ultrasound for Needle guidance, aspiration
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US Muscle identification
• Identification of muscles is based on pattern recognition of – Contour lines – Adjacent structures
• Bones • Vessels • Other muscles
– Real-time • Use AROM/PROM to
assist muscle identification
Pronator teres FCR
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US Scanning Demonstration
• Transducer handling/manipulation • Scanning limbs/structures • Injection Techniques
– In plane – Out of plane
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Hands On Course Agenda
• Demonstration/projection of muscle groups • Following the demonstration each group will
practice scanning – The following key muscles will be demonstrated
• Pectoralis Major/Teres/Subscapularis • Biceps/Brachialis/Musculocutaneous nerve • FCR/FCU/Pronator Teres • FDS/FDP/FPL
– Procedural Guidance Techniques • Rotate to this station when you are waiting to scan or
finished scanning
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MUSCLE IDENTIFICATION/REVIEW Slides will be available on line
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Trapezius
Middle Fibers/Upper Shoulder Transverse Sccan R and L Out of Plane Injection
Video Link:Trap R L OP Inj NS.wmv
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Teres Major Transverse View: Teres/Lat
Out of Plane Injection
VideoLink:Teres Maj Tv OP BB
Teres Maj Tv
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Pectoralis Major/Minor
Page from Ultrasound Guided Chemodenervation Procedures, Text and Atlas Demos Medical 2012
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Biceps/Brachialis Transverse Scan, Out of Plane Inejction
Biceps, Transverse Mid Arm Out of Plane Injection
Video Link: Biceps Tv OP Video Link: Biceps Tv OP P5311410.AVI
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Brachioradialis
Transverse Scan, Out of Plane Transverse Scan
Picture Link: BR TV K1.png
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Flexor Forearm, Proximal
Page from Ultrasound Guided Chemodenervation Procedures, Text and Atlas Demos Medical 2012
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Flexor Forearm Transverse Scan, Proximal Forearm
Flexor forearm Transverse FOREARM
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FDS FDS Transverse Transducer Location Forearm transverse, AROM
Video: FDS AROM TV 9 4261.mpg FDS Tv
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FDP
Typical Approach for FCU/FDP Longitudinal Scan:,FDP F
FDP FCU LA OP
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Flexor Pollicis Longus Longitudinal Scan
Longitudinal Scan AROM
Video Link:FPL LA AROM CN1.wmv
Picture Link: FPL Long LAx1.jpg
Picture Link:FPL LA CN1.png
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Ultrasound for BoNT Therapy • For many reasons, clinicians who
use US consider it to be a more/the most accurate localization method for BoNT – Owing to
• Direct visualization of target structure and needle placement
• Image quality • Access to portable US systems • Expertise of clinicians